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COPYRIGHT DEPOSIT 



PULMONARY 



TUBERCULOSIS 



BY 

MAURICE FISHBERG, M.D. 

CLINICAL PROFESSOR OF MEDICINE, NEW YORK UNIVERSITY AND BELLEVUE HOSPITAL 

MEDICAL COLLEGE; ATTENDING PHYSICIAN, MONTEFIORE HOME AND 

HOSPITAL FOR CHRONIC DISEASES, NEW YORK 



SECOND EDITION, REVISED AND ENLARGED 



ILLUSTRATED WITH 100 ENGRAVINGS AND 25 PLATES 



v 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1919 



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Copyright 

LEA & FEBIGER 

1919 



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LA525208 



APR 24 1919 



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TO 
MY WIFE 



PREFACE TO THE SECOND EDITION. 



It is the purpose of this book to supply the general practitioner 
with information concerning the etiology, diagnosis, prognosis and 
treatment of pulmonary tuberculosis, its clinical forms and common 
complications. An experience of over twenty years with the tuberculosis 
problems in New York City has convinced the author that: (1) The 
physician can, and should, do more than recognize phthisis in its earliest 
or pretuberculous stage and at once consign the patient to a sanatorium. 
(2) That " incipient" does not always mean curable tuberculosis, and 
conversely, that "advanced" disease does not necessarily indicate a 
hopeless outlook. (3) That institutional treatment is not the only 
effective method of handling the phthisical patient. (4) If all tuber- 
culous persons in this country would consent to hospitalization, the 
available institutions would hardly accommodate ten per cent, of 
eligible patients. (5) Even those treated in sanatorium s must be 
cared for by their family physicians before admission and after dis- 
charge. (6) Careful home treatment is productive of practically the 
same immediate and ultimate results as institutional treatment, and is 
less costly to the patient and to the community. 

Recent investigations of tuberculous infection have radically changed 
our views on the transmissibility of tuberculosis. On the one hand, 
it was found that patients who indiscriminately expectorate tubercle 
bacilli are a greater menace than has hitherto been suspected. Infants 
may be infected by mere contact with phthisical persons. On the other 
hand, there is hardly a person living in a large city who has escaped 
infection with tubercle bacilli. In other words, despite the vigorous 
and costly efforts which have been made during the past thirty years, 
the majority of the population in civilized countries harbor tubercle 
bacilli in their bodies. But, what is of more importance, not every 
one infected with tubercle bacilli is destined to become sick. For this 
reason, a sharp distinction is made in the following chapters between 
infection and disease, or tuberculosis and phthisis. 



vi PREFACE 

Recent research has also shown that infection with tubercle bacilli 
endows an organism with a certain degree of resistance, or even im- 
munity, against further and renewed exogenic infection with the same 
virus. Experimental investigations have proved that it is impossible to 
reinfect a tuberculous animal with tubercle bacilli. Many clinical 
phenomena, which have hitherto baffled those who studied the disease, 
such as the rarity of conjugal phthisis, or of tuberculous disease in those 
living and working among phthisical patients, and of soldiers in the 
armies, are now explained by this immunity of the tuberculous against 
reinfection with tubercle bacilli. Phthisis is at present considered a 
manifestation of immunity. Prophylaxis of infection has been shifted 
to the child, while that of phthisis involves more than prevention of 
infection. 

In the discussion of the clinical aspects of phthisis an attempt has 
been made to elaborate on the constitutional symptoms, which are 
still the sheet-anchor of the physician who is charged with deciding 
whether a patient is ill and in need of treatment. Bacteriology and 
serology are excellent helps in showing whether the patient has been 
infected with tubercle bacilli; skiagraphy reveals airless areas of lung 
tissue; but they do not give conclusive proof that the patient is sick 
and in need of prolonged and costly treatment. We also know that 
unity of causation is not always an indication of unity of resulting 
clinical phenomena in tuberculosis : The clinical picture of tuberculosis 
in infants is different from that in children; in adults some, irrespective 
of the treatment applied, show a marked tendency to sclerosis or fibrosis 
of the lesion; in others caseation and destruction of lung tissue go 
on progressively; in still others there is a sluggish course, marked by 
periods, of illness alternating with periods of comparative comfort. 
For these reasons several types of the disease, or syndromes, have 
been described, each of which has not only a different clinical course, 
but also a different outlook as to recovery, and the treatment differs 
markedly in each form of the disease. 

It appears that the tuberculosis problem has been handled in the 
various armies engaged in the recent World War along the lines men- 
tioned above and some have anticipated that the disease will prove as 
great a menace as many other war plagues, such as typhoid, influenza, 
dysentery, etc. However, despite the fact that only clinical tuberculosis 
has been considered cause for rejection by draft boards, and tuberculin 
(the test for infection) has not been applied for diagnostic purposes at 
all, the number of cases of active tuberculosis in the armies has not been 



PREFACE vii 

excessive, considering that soldiers are of the age period when the disease 
is most likely to occur. This clearly has been an experiment on a large 
scale showing that tuberculous infection is not acquired by adults; that 
infection, which is in the vast majority of cases acquired during child- 
hood, is not invariably followed by disease, and that only constitu- 
tional symptoms decide whether a patient is sick with phthisis and in 
need of treatment. Our rather unconventional views on the diagnosis 
and prophylaxis of phthisis as a disease, which have been emphasized 
in the first edition of this book, have thus been fully confirmed. Though 
infection as a factor in phthisiogenesis has been practically disre- 
garded in the various armies engaged in the recent war, no visible 
harm has resulted. 

The treatment recommended in this book is based on experience 
with patients in New York City. Some were living in the congested 
neighborhoods of the Metropolis; others in the better parts of the city; 
still others have been under the author's care in the hospital. A large 
proportion had been in sanatoriums, but even they had to be cared 
for in their homes before admission and after discharge. Emphasis 
is laid on the fact that in most cases we can give the patient the benefit 
of modern and approved treatment in his home as well as in institutions. 
The immense utility of sanatorium treatment is emphasized and its 
limitations are enumerated. It is also shown that institutional treat- 
ment is not the only, nor the best, available method of caring for the 
majority of patients. Experience has taught that we can properly 
house and feed a patient in the city at a much less expense than in a 
sanatorium. 

Medicinal treatment has been alloted some space for the reason that 
it is, in many cases, believed to possess more value than it has been 
accredited by therapeutic nihilists. The most recent method of treat- 
ment, artificial pneumothorax, has been given at some detail because 
of its efficacy in selected patients in whom everything else has failed to 
afford relief. 

In this new edition nearly every chapter has been revised and several 
have been rewritten. The influence of influenza on the etiology, 
course and prognosis of phthisis has been given in the light of recent 
experience. New chapters on tuberculosis of the pleura and on pneu- 
mothorax have been added. The differential diagnosis of tuberculosis 
has been more extensively treated in a new chapter, giving details 
about the clinical differentiation of cardiac disease, rhinopharyngeal 
conditions, bronchiectasis, bronchopulmonary spirochetosis, pulmo- 



vin PREFACE 

nary streptotrichosis, pleural vomicae, cancer of the lung, influenza, etc. 
Several additional plates have been inserted illustrating the pathology 
of pulmonary tuberculosis, all drawn from specimens obtained at 
necropsies at the Montefiore Hospital of cases under the author's care. 
Many of the radiographic plates have been replaced, and several new 
ones have been added, so that these illustrations, nearly all prepared 
under the supervision of Dr. Thomas Scholz, radiographer to the 
Montefiore Hospital, represent practically an atlas of radiography of 
pulmonary tuberculosis. 

M. F. 

New York, 1919. 



CONTENTS. 



CHAPTER I. 
The Tubercle Bacilli 17-36 

CHAPTER II. 
Tuberculous Infection 37-55 

CHAPTER III. 
The Epidemiology of Tuberculosis 56-83 

CHAPTER IV. 
Factors Predisposing to the Evolution of Phthisis 84-115 

CHAPTER V. 
Phthisiogenesis 116-133 

CHAPTER VI. 
Pathology and Morbid Anatomy 134-155 

CHAPTER VII. 
Symptomatology of Phthisis — History of the Patient .... 156-163 

CHAPTER VIII. 
Cough and Expectoration 164-180 

CHAPTER IX. 
Fever and Nightsweats 181-200 

CHAPTER X. 
Hemoptysis 201-222 

CHAPTER XI. 

Symptoms Caused by Disturbances in the Gastro-intestinal 

Tract— The Skin— The Joints 223-238 



x CONTENTS 

CHAPTER XII. 
Symptoms Referable to the Cardiovascular and Renal Systems 239-250 

CHAPTER XIII. 
Nervous Symptoms of Phthisis 251-262 

CHAPTER XIV. 
Inspection and Palpation 263-273 

CHAPTER XV. 
Percussion of the Chest in Phthisis 274-295 

CHAPTER XVI. 

Auscultation of the Chest in Phthisis 296-312 

CHAPTER XVII. 
Skiagraphy in the Diagnosis of Phthisis 313-323 

CHAPTER XVIII. 
The Clinical Forms of Phthisis 324-330 

CHAPTER XIX. 

Chronic Phthisis. Incipient Stage 331-349 

CHAPTER XX. 
Chronic Phthisis. Advanced Stage 350-367 

CHAPTER XXI. 
Acute Phthisis 368-374 

CHAPTER XXII. 
Fibroid Phthisis ■ . 375-384 

CHAPTER XXIII. 
Abortive Tuberculosis 385-388 

CHAPTER XXIV. 

Pulmonary Tuberculosis in Children 389-414 



CONTENTS xi 

CHAPTER XXV. 
Phthisis in the Aged 415-418 

CHAPTER XXVI. 
Tuberculosis of the Pleura 419-457 

CHAPTER XXVII. 
Pneumothorax 458-470. 

CHAPTER XXVIII. 
Differential Diagnosis of Pulmonary Tuberculosis .... 471-491 

CHAPTER XXIX. 
Complications of Phthisis 492-511 

CHAPTER XXX. 

Prognosis in Pulmonary Tuberculosis 512-528 

CHAPTER XXXI. 
The Indications for Treatment of Phthisis 529-536 

CHAPTER XXXII. 
Prophylaxis 537-552 

CHAPTER XXXIII. 
General Management of the Case 553-564 

CHAPTER XXXIV. 
The Rest Cure 565-573 

CHAPTER XXXV. 
Open-air Treatment 574-585 

CHAPTER XXXVI. 
Climatic Treatment 586-598 

CHAPTER XXXVII. 
Institutional Treatment 599-607 



xii CONTENTS 

CHAPTER XXXVIII. 
Dietetic Treatment 608-620 

CHAPTER XXXIX. 
Medicinal Treatment 621-633 

CHAPTER XL. 
Specific Treatment 634-643 

CHAPTER XLI. 
Symptomatic Treatment 644-665 

CHAPTER XLIL 
Operative Treatment — Artificial Pneumothorax 666-701 

CHAPTER XLIII. 

General Treatment of the Various Forms of Pulmonary Tuber- 
culosis 702-713 

CHAPTER XLIV. 

Treatment of Complications 714-721 

Index of Authors 723-730 

Index of Subjects 731-744 



PULMONARY TUBERCULOSIS. 



CHAPTER I. 
THE TUBERCLE BACILLI. 

That tuberculosis is a transmissible disease had been suspected 
by many ancient physicians and conclusively proved by Villemin in 
1865, but it remained for Robert Koch 1 to isolate the microorganism 
which is the infective agent. In 1882 he published his first com- 
munication describing the morphology, staining reactions, cultivation, 
and the successful animal inoculation of pure cultures of the bacilli 
invariably found in tissues affected with tuberculosis. 

The tubercle bacillus is a parasite in the full sense of the word, 
living and thriving only in the bodies of animals and man, and perish- 
ing outside of the animal body. It has not been decided to which 
group of microorganisms it belongs; in fact, we do not as yet have 
a classification of bacteria which is completely satisfactory to all who 
are competent to judge. It may be said to belong to the group of 
acid-fast bacteria, of which there are many varieties to be mentioned 
farther on, and may be classified with the trichomycetes, while some 
consider it intermediary between the true bacteria and the lower 
fungi, the hyphomycetes. 

Morphology. — The morphological variations of the tubercle bacilli 
are dependent on their type and virulence, whether human, bovine, 
or avian, and on the media in which they have been cultivated. In 
film preparations made from cultures, or from sputum expectorated 
by tuberculous patients, the tubercle bacillus appears as a slender 
rod, usually straight, but very often curved, about one-fourth to one- 
half the diameter of a red blood corpuscle, or 5-^ mm. in length, on 
the average. These rods, mostly rounded on the two ends, are seen 
in the preparations from secretions or tissues, singly, in pairs, or in 
heaps, occasionally imbedded in the tissue cells. They are non-motile, 
and have no flagella. Microscopically, an enveloping or capsular 
substance can often be made out around each bacillus, especially in 
those which have been artificially cultivated in serum for several 
generations. Some individual bacilli are strikingly pleomorphic, 

1 Berl. klin. Wchnschr., 1882, xxxix. An English translation of the complete report, 
originally appearing in Mitt, aus dem Gesundheitsamte, 1887, vol. ii, made by Stanley 
Boyd, has appeared in "Recent Essays on Bacteria in Relation to Disease," New 
Sydenham Society, 1886, pp. 65-201. 
2 



Is THE TUBERCLE BACILLI 

thread, or club-shaped, with thickenings at either or both ends, or with 
filaments passing out from the main rod at right angles, and finally 
in Y-shaped branchings. But these are of no practical significance, 
because they appear to be simply degenerated types of the micro- 
organism, although some look at them as the reverse, the result of 
active growth on a good culture medium, and amid favorable biological 
surroundings. In some individual bacilli, vacuoles are seen, giving 
the rod the appearance of a chain of cocci. The suggestion that they 
represent spores appears to be erroneous, because they have no stronger 
resistance than the body of the bacillus, and succumb to heat and 
chemicals as fast as the entire rod. The fact that it is speedily killed 
by sunlight also indicates that the tubercle bacillus has no spores. 

Staining. — The tubercle bacilli stain with basic dyes, but with 
great difficulty, and, once stained, they part with the color with diffi- 
culty. Their most important characteristic is their acid-fast property. 
While other microorganisms lose their stain when treated with acids 
or alcohol, the tubercle bacilli retain it. They are also alkali-fast, 
and when stained by an acid dye cannot be decolorized by an alkali. 
But it must be mentioned that they are not the only known acid-fast 
bacilli. This is one of the sources of error which, at times, interferes 
with the proper appreciation of acid-fast microorganisms discovered 
under the microscope. 

Much's Granules. — There have also been found tubercle bacilli 
which, while remaining virulent, have lost their acid-fast characters. 
Hans Much, 1 who has studied these microorganisms, and by whose 
name they are generally known, describes two forms of these granules : 
(1) A rod-shaped granular organism; (2) isolated granules; both of 
which cannot be stained by the Ziehl method, but only by the Gram 
method. They are pathogenic to animals and man, and are usually 
found in some cases of slowly progressing chronic phthisis, fibroid 
phthisis, cold abscess, etc. It is thus evident that before concluding 
that a given case lacks acid-fast bacilli, and is therefore not tuberculous, 
the Much granules are to be looked for by staining with the Gram- 
Much method. According to W. H. Park, true tubercle bacilli are 
probably always present together with the granules in cases in which 
the latter forms are found. 

In this country Charles N. Meader 2 has made a careful study of 
these granules. In his opinion "the biological relationship of Much's 
forms of tubercle bacilli is a matter of considerable interest. They 
may be considered as a natural stage in the evolution of the bacillus, 
as the result of degenerative changes, or may be classed as spores 
(i. e., as resisting forms). The accumulated evidence tends to show 
that they are predominantly found in tissues of a distinctly fibroid 
character, in old cavities, in pus of cold abscesses, in old cultures, in 
the notably indolent lupus lesions and in sclerosed lymph glands — 

1 In Brauer, Schroder, and Blumenfeld's Handbuch d. Tuberkulose, i, 193. 

2 Am. Jour. Med. Sc, 1915, el., 858. 



POWERS OF RESISTANCE 19 

facts which, taken together, mark them as forms assumed under 
unfavorable conditions, whether they be the result of sporulation or 
of degeneration. The same conclusion is suggested by observations 
that, under favorable cultural conditions, they are rapidly replaced 
by Ziehl-staining forms. Against their classification as spores, in the 
commonly accepted sense, is the fact that the granular forms are rather 
less resistant to the action of antiformin than are the Ziehl forms; their 
resistance to other chemical agents has not yet been reported upon. 
It is of interest to note here that the granular forms appear more 
frequently in the bovine than in the human type of bacillus." 

Cultivation. — The tubercle bacilli are obligatory aerobes; they re- 
quire free oxygen for maintenance of life, activity and propagation. 
In artificial media they grow very slowly, much more slowly than most 
bacteria which are not acid-alcohol-fast; they proliferate very slowly, 
and other saprophytic microorganisms which happen to live with them 
soon outnumber them. It is also worthy to remember that it is diffi- 
cult to cultivate them directly from tuberculous lesions, secretions 
and excretions of patients known to contain tubercle bacilli. But 
once they have been cultivated, it is rather easy to transplant them 
to another culture of the same medium, and growth is even more 
luxuriant in the subsequent cultures. Theobald Smith's method of 
cultivation on dog serum and Dorset's egg medium, and especially 
Petroff's medium, are about the best and most used in this country. 
Pure cultures are best obtained from tubercles of animals inoculated 
with the bacilli. But it is often possible to obtain pure cultures from 
closed tuberculous cavities, from lesions of lupus, and even from sputum. 

When cultivated on coagulated dog serum, or bovine serum, or in 
Dorset's egg medium, especially when to the latter there is added 
glycerin, growth appears usually at the end of ten days at 37° C, 
and within four weeks the characteristic growth may be expected. 
On the glycerin-egg medium the human form of organism produces 
an abundant, wrinkled layer, usually having a yellowish, buff, or 
pinkish color. The growths are seen as more or less elevated colonies 
which may coalesce. On glycerin-agar the growth is more rapid than 
on serum, and appears as a thick, white layer, becoming yellowish. 
Tubercle bacilli also flourish in glycerin-potato medium. 

Powers of Resistance. — The tubercle bacilli grow best at the tem- 
perature of the human body, 37° to 38° C, but growth is not abolished 
at 29° to 42° C. From a practical standpoint it is important to men- 
tion that they are not killed when exposed to moist heat of 50° C. 
for less than twelve hours, but heating to 55° C. for four to six hours 
does destroy them. They are also killed when exposed to moist heat 
of 60° C, for one-half hour, and in fifteen minutes at 70° C; in five 
minutes at 80° to 90° C, and in one minute at 95° C. With sputum, 
conditions are different: the mucus protects the bacilli and it requires 
more time to destroy them with heat. However, five minutes' boiling 
is sufficient to kill the bacilli under all circumstances. 



20 THE TUBERCLE BACILLI 

Another practical point is that in milk, tubercle bacilli resist the 
action of heat with greater tenacity than in pure liquid cultures, or 
eveo in sputum. From many careful experiments it appears that heat- 
ing milk for thirty to forty minutes, at a temperature of 65° to 70° C, 
or boiling for three minutes, destroys tubercle bacilli. Especially 
resistant are the bacilli when the milk is heated in an open vessel and 
a pellicle forms on the top of the fluid. This protects the bacilli against 
a temperature of 60° C. for an hour. William H. Park explains this 
by the fact that the upper parts of the fluid are not heated to the 
same degree as the lower, and some bacilli may survive. At any rate, 
it is important that pasteurization should be done in closed vessels. 
In butter the virulence of the bacilli is greatly diminished and even 
abolished when in contact for a long time. In fact, they die out within 
a few weeks, as a rule. The reasons for this phenomenon are not 
clear. On the other hand, Schroeder and Cotton have found living 
tubercle bacilli retaining their virulence for one hundred and sixty days 
in salted butter when kept without ice in a house cellar; and Mohler, 
Washburn, and Doane found that they survived a year in cheese. 
In thoroughly boiled or roasted meat the bacilli are destroyed; but 
in the rare portions they may survive. Sausages, etc., made of 
uncooked meat, may contain living tubercle bacilli. 

Dry heat is less potent in destroying tubercle bacilli; circulating 
steam requires one-half hour for this purpose, while bacilli in dried 
sputum can withstand a temperature of 100° C. for an hour. On 
the other hand, cold does not destroy their virulence, and freezing, 
with subsequent thawing, does not hai*m them very much. 

It is also important to remember that the fatty substances and 
wax contained in the tubercle bacilli protect them to a certain extent 
from the effects of desiccation, and from the bactericidal action of 
the normal body cells, although for growth and proliferation they 
require moisture. When dried and pulverized by being converted 
into dust, as is often the case with tuberculous sputum eliminated 
indiscriminately by careless patients, most of the bacilli succumb, 
but some have been found to resist desiccation at ordinary tempera- 
ture for months. 

In this connection it must be borne in mind that the action of light 
is an important factor. It has been ascertained that light, especially 
sunlight, decomposes the fatty substances in the bacilli and thus 
destroys them altogether. When cultures are exposed to direct sun- 
light for a couple of hours, the vitality as well as the virulence of the 
tubercle bacilli is destroyed; in sputum the bacilli are protected by 
the mucus, and it requires a longer time for their destruction. Some 
maintain that their virulence is destroyed with only partial loss of vitality. 

Under the circumstances sputum eliminated in light places is sooner 
or later rendered harmless, while when expectorated in dark rooms 
the bacilli may retain their vitality and virulence for a year, and even 
drying does not harm them much. 



POWERS OF RESISTANCE 21 

On the whole, tubercle bacilli may retain their vitality for a con- 
siderable time if not in exceptionally unfavorable surroundings. In 
the latter case their growth is soon hampered, and they cannot suc- 
cessfully be transferred by inoculation to another culture medium; 
but they may retain their virulence much longer and cause disease 
when inoculated into animals. After several months, however, even 
this wanes, and after six months this property is completely lost. In 
laboratories it has been found by experience that it is safer to reinocu- 
late cultures every four to six weeks. Exceptionally, cultures have 
been found alive and virulent after two years. This is especially the 
case with potato and bouillon cultures which have been kept under 
favorable conditions, as to heat, moisture, etc., while in serum and 
glycerin cultures the bacilli do not survive so long. 

Cornet found that serum cultures remain alive for about six months, 
while glycerin-agar cultures are often partially, or wholly, dead in six 
to eight weeks. There seems also to be some difference in this respect 
between the various types of tubercle bacilli: Maffucci states that 
avian bacilli may remain alive for two years, and Strauss found that 
cultures of human tubercle bacilli are only exceptionally capable of 
reproduction after five to six months; after eight to twelve months 
they fail regularly. Theobald Smith 1 found that a culture three months 
old failed, as a rule, to yield successful subcultures, and that tubercle 
bacilli, of both human and bovine types, when kept in fully developed 
cultures at 40° to 50° F., may remain infectious to guinea-pigs for from 
seven to nineteen months, but the number of bacilli surviving in such 
cultures is relatively small. Delepine's 2 experience has been that 
tubercle bacilli retain some of their pathogenicity as long as 500 days 
if left in the dark in milk at a low temperature, below 6° C; but 
after being kept thus for four and one-half years these bacilli, were no 
longer pathogenic to guinea-pigs. It is, however, important to bear 
in mind, when considering prophylaxis, that when tubercle bacilli in 
sputum are deposited in dark rooms they may retain their vitality and 
power to cause disease for as long as 309 days, as has been found by 
Soparkar. 3 The oldest tuberculous sputum which has been inves- 
tigated was that reported by Newell Bly Burns. 4 He examined 
sputum twenty-two years old and found that the bacilli retained 
their staining qualities but lost completely their power to grow and 
their pathogenicity. 

Tubercle bacilli display great powers of resistance to the action of 
the products of other bacterial growths, in spite of the fact that they 
have no spores. They may survive for months in souring milk, in 
sewage and in water, and in putrefying matter generally, especially 
sputum. Lawrason Brown, 5 S. A. Petroff and F. H. Heise found viru- 

1 Jour. Med. Research. 1913, xxviii, 91. 

2 Ann. de l'lnst. Pasteur, Paris, 1916, xxx, 600. 

3 Indian Jour, of Med. Research, 1916, iv, 62. 

4 Araer. Review of Tuberc, 1917, i,.484. 

5 Tr. Nat. Assn. Prevent. Tuberc, 1916, xii, 286. 



22 Tin: tVbercLe MctLLl 

lent tubercle bacilli in the water of the Saranac River, into which 
the sewerage system of Saranac Lake empties. Every sample of water 
taken from below the surface, from the outlet of the sewer to a point 
three and a half miles down the stream, showed the presence of acid- 
Fast organisms. No acid-fast organisms were found above the outlet 
or twelve miles below the outlet. The bacilli are believed to be derived 
from the feces of the numerous tuberculous individuals in Saranac. In 
fact, where no particles of feces were discovered in the water, no viable 
tubercle bacilli were found. 

Virulence. — Long before the discovery of the tubercle bacillus it 
was known that certain diseases in animals were of the same character 
as human tuberculosis, and attributed to the same virus. Klenke, in 
1846, emphasized the danger of milk from tuberculous cattle as an 
infective agent to human beings, and Villemin, in 1865, showed by 
animal experiment that tuberculous disease in man and animals is 
identical in character. With the study of the virulence of the tubercle 
bacillus it was found that it is pathogenic to many species of animals. 
In some tuberculosis is known to occur spontaneously, while others 
may be infected artificially. There appear to be significant differences 
in the results of such experimental infections, depending on the method 
of inoculation of the virus — injections into the subcutaneous tissues, 
into the peritoneum, into the anterior chamber of the eye, intrave- 
nously, by feeding animals with bacilli, or compelling them to inhale the 
bacilli with inspired air, and also according to the origin of the bacilli. 

Tubercle bacilli obtained from different cases of human tuberculosis 
often show differences in their virulence according to the strain. But 
when the bacilli obtained from different animals are compared, the 
differences in their virulence are even more striking. For this reason 
there have been described different spe?ies, varieties or strains of 
tubercle bacilli, although some authors maintain that the differences 
in cultural and virulence characteristics are acquired while the micro- 
organisms are sojourning in the host by adaptation to the conditions 
favorable for their growth. 

HUMAN, BOVINE, AND AVIAN BACILLI. 

In the early history of the scientific investigation of tuberculous 
infection it was already noted that there are some differences between 
human and bovine tubercle. Villemin was the first to find these differ- 
ences. "We must note that none of our rabbits," he said, "inoculated 
with human tubercle have presented a tuberculization so rapid and gen- 
eralized as that which we have obtained with material from the cow. 
At first we were inclined to regard this as fortuitous, but subsequent 
experiment led us to suppose that the tubercle of the bovine race 
inoculated into rabbits possesses a much greater activity than that 
obtained from man. It may be supposed that, like all virulent matter, 
the tuberculous matter is the more virulent the more the affinitv of 



HUMAN, BOVINE, AXD AY I AX BACILLI 23 

the animal supplying the virus and the animal receiving it." This ap- 
parently was entirely forgotten, until Nocard and Roux. and Rivolta 
and Maffucci again rediscovered it while doing inoculation experiments 
with tubercle bacilli derived from humans and from cattle. 

It remained, however, for Theobald Smith 1 to make the first care- 
ful study of differences in morphological, cultural, and pathogenic- 
types of tubercle bacilli. In 1S9S he showed that there are differences 
between the bacilli isolated from human beings, when compared with 
those isolated from cattle. His designation of the former as "human," 
and the latter as '"bovine," has since been, generally accepted. In 
1901 Robert Koch also announced that his studies led him to the con- 
viction that human and bovine tuberculosis are not identical: that the 
bovine bacilli are, in fact, not pathogenic to man, and that no special 
measures need be taken to protect man against the consumption of 
milk and meat from tuberculous cattle. Considering the commercial 
interest which is centered around this problem, in addition to the 
problem of human infection, it is clear why studies along these lines 
have been in abundance during recent years. 

Still other types of bacilli have been found. Rivolta and Maffucci 
have shown that there are certain morphological and biological dif- 
ferences between the tubercle bacilli found in birds and those in 
human beings. Theobald Smith continued to investigate the prob- 
lem and arrived at the conclusion that bacilli from human sources 
are not clearly identical in every respect with those obtained from 
bovine sources. Official bodies of the Imperial Department of Health 
in Germany, a Royal Commission in England, and Dr. William H. 
Park, for the New York City Department of Health, have thoroughly 
studied the problem, each from a different angle. The result is that 
we are at present in a position to state conclusively that there is more 
than one variety of tubercle bacillus. 

The conclusions of the British Royal Commission are to the effect 
that "for the purpose of description it is advantageous to distin- 
guish three types of tubercle bacilli, recognizable by their individual 
characters. These are the human, the bovine, and the avian. The 
human type, although so named, is not the only one found in cases 
of tuberculosis in man. It is the organism present in the majority 
of such cases, but in some cases of human disease the bacilli present 
are of the bovine type, and in others the bacilli have special charac- 
ters distinguishing them from each of the three principal types. In 
natural cases of tuberculosis in cattle the only type of bacillus present 
is the bovine type." William H. Park 2 concludes from his extensive 
study of the subject that "tubercle bacilli, as isolated from man. fall 
into two groups. One of these groups is identical in all its characters 
with those found in cattle. That is. all tubercle bacilli from man and 



1 Jour. Exper. Med.. 159b. iii. 451. 

■ Jour. Med. Research. 1911. xx, 313: 1912. mi, 109. 



2 1 THE TUBERCLE BACILLI 

cattle fall into two groups, which have been designated the human 
and bovine types." 

Human Bacilli. — The human variety grows on all culture media 
quickly and luxuriantly; the addition of glycerin enhances their 
growth. On' glycerin bouillon growth is seen during the first few days, 
and within three weeks there is seen a pellicle on the surface of the 
culture which spreads laterally and reaches the glass walls. The pellicle 
is fragile and its surface wrinkled. Morphologically, the human bacilli 
when grown on serum cultures appear as long, straight, or curved rods 
which are unevenly stained. 

In general it may be stated that the virulence of human bacilli is 
rather low in various animals. Guinea-pigs are very susceptible and 
may be infected in various ways, even by rubbing the bacilli into the 
shaved skin of the abdomen. Rabbits are, however, less susceptible. 
Even when a milligram of bacilli is injected into a vein of the ear 
there is only produced a chronic lesion which may heal; subcutaneous 
injection produces an infiltration at the point inoculated which soon 
softens and empties itself through a fistulous opening, or may even 
be absorbed. The regional lymph glands swell, but do not caseate. 
At times, but not in every case, there may thus be produced a chronic 
infection of the lungs in the rabbit. Intraperitoneal inoculation pro- 
duces tuberculous peritonitis, which may extend along the diaphragm; 
infection of the anterior chamber of the eye produces a lesion which 
develops more slowly than when bovine bacilli are used. Cattle 
are infected when large doses are injected intravenously. But with 
subcutaneous infection there is produced only an infiltration at the 
point inoculated, which soon suppurates and heals. The regional 
lymph glands swell up and at times become calcified. Feeding calves 
with human bacilli never produces any progressive disease. Pigs, dogs, 
cats, and sheep are not at all affected by human bacilli, while mon- 
keys are very susceptible. Some species of birds are also susceptible. 

Bovine Bacilli. — The bovine bacilli are very difficult to cultivate; 
it appears that the addition of glycerin to the culture medium slackens 
their growth. On glycerin bouillon growth is very slow. A thin 
pellicle is formed which spreads all over the surface within four to 
eight weeks, but it may remain limited to the center of the surface. 
Only rarely are a few verrucose thickenings formed on the surface. 
After several transplantations they may show greater tendencies to 
grow. Morphologically, they appear as shorter, thicker, and more 
evenly stained than the human variety, and usually bent, showing bead- 
ing and irregularities in staining. Park, who has done excellent work 
along these lines, says: "Although one could in many instances 
make a probable diagnosis of type from an inspection of the smear, 
the number of intermediate gradations in morphological differences 
rob it of nearly all its practical value. " 

The bovine bacilli are more virulent for rabbits, calves, and swine 
than the human. Guinea-pigs are just as susceptible to them as 



HUMAN, BOVINE, AND AVIAN BACILLI 25 

they are to the human variety, but in addition they are killed, or 
become acutely and progressively sick, when infected with small 
doses of bovine bacilli. The difference in the virulence of the two 
types is well seen in the rabbit. The bovine type of virus causes in 
every instance a generalized miliary tuberculosis, progressive, and 
causing the death of the animal. " Human virus injected in the 
same amount produces either no disease at all, or lesions of varying 
severity in the lungs or kidneys or both, and never causes generalized 
miliary tuberculosis. Even with 1 mg., that is, one hundred times 
as much, the lesions are usually confined to the same organs, and 
though there is a very slight tendency to generalization with this 
dose, there is never a generalization showing a progressive nature. 
Rabbits injected even with the larger dose live indefinitely, and, if 
death should occur, the tuberculous lesions are usually not extensive 
enough to say that the animal died of the disease." (Park and 
Krumwiede.) 

Cattle are also very susceptible to the bovine virus, and after intra- 
venous injection perish from generalized tuberculosis within three or 
four weeks. Intraperitoneal, intraocular, ard intramammary inocu- 
lation also cause generalized and fatal tuberculosis. Feeding cattle, 
with even small doses of pure culture of bovine tubercle bacilli causes 
tuberculous disease of the intestines, followed by tuberculous lymph- 
angitis and lymphadenitis of the mesentery; the disease spreads to 
other lymph glands, serous membranes, and lungs. Inhalation pro- 
duces caseous pneumonia. After subcutaneous injections there is 
produced an infiltration at the point inoculated, swelling of the regional 
lymph glands, and generalized tuberculosis, the animal perishing 
within two or three months. Pigs, sheep, goats, cats, and monkeys 
are very susceptible; dogs, rats, and mice are more or less refractory. 
Some species of birds are susceptible, but chickens show complete 
resistance. 

Avian Bacilli. — On glycerin agar and on serum their growth is more 
luxuriant, appears more moist, or slimy, than observed in mammalian 
bacilli, and they produce an orange pigment. They grow at the tem- 
perature of 41° C., which stops the growth of mammalian tubercle 
bacilli. Morphologically, the differences are insignificant. The Royal 
Commission found that rabbits, rats, and mice are the only mammals 
susceptible to inoculation with avian tubercle bacilli. Fowls are very 
susceptible when fed with portions of the organs containing avian 
bacilli, but they may consume enormous quantities of phthisical spu- 
tum without becoming tuberculous. On the other hand, the parrot 
is susceptible to both human and bovine bacilli as well as to avian, 
and spontaneous tuberculosis may be due to any of the types. Tuber- 
culosis is very common among domesticated birds and there have been 
observed veritable epidemics of the disease in poultry yards. 

Tubercle Bacilli of Cold-blooded Animals. — Certain diseases ob- 
served in worms, lizards, frogs, turtles, snakes, and fish have great 



L'C, LIIK riHERCLE BACILLI 

resemblance to human tuberculosis and in many cases acid-fast bacilli 
have been isolated. These microorganisms grow luxuriantly at the 
room temperature, the growth being thick and moist like that of 
avian bacilli, and a higher temperature than 30° C. inhibits their 
growth. While they do not grow at the body temperature, it appears 
that some have been able to acclimatize them to a temperature of 36° 
C. Weber and Taute have cultivated this microorganism from mud, 
and also from healthy frogs. They therefore conclude that these 
acid-fast bacilli have nothing in common with tubercle bacilli, but 
they are saprophytes which may be found in healthy animals and in 
the soil. Others, however, consider them as true pathogenic bacilli 
of cold-blooded animals, or such as have become attenuated in their 
virulence by a long residence in, and adaptation to growth at, a lower 
temperature. 

Attempts have been made to use these bacilli for the purpose of 
immunization against infection with mammalian tubercle bacilli, but 
they were unsuccessful. F. F. Friedmann has even claimed that 
bacilli obtained from turtles are curative of existing tuberculous 
disease, but the results obtained have not justified in the slightest 
his pretensions. 

Other Acid-fast Bacilli. — The tubercle bacilli are not the only variety 
of microorganisms which, once stained, refuse to be decolorized by 
acids and alcohol. There have been found many others presenting 
the same staining reactions as the tubercle bacilli, and there is no 
doubt that they may bring about confusion in diagnosis. Of these 
we may mention the following: 

The smegma bacillus is a slender, slightly curved rod, not unlike 
the tubercle bacillus but distinctly shorter, and resists the action of 
acids after staining. It is found in the secretions of the external 
genitals, mamma?, etc., especially when these secretions contain fatty 
matter. There have been reported cases in which extirpation of kid- 
neys was performed as a result of mistaking these microorganisms for 
tubercle bacilli. 

The Bacillus lepra? also has great similaritv to the tubercle bacillus. 
(See Plate I.) 

Moller's grass bacilli are found in infusions of timothy-grass 
(phleum pratense), resemble morphologically the tubercle bacilli, and 
are acid-fast. Inoculations produce lesions exquisitely resembling 
tubercles. 

Moller has also described a bacillus found in milk, even in pasteur- 
ized milk, according to Kuthy. Its similarity to the tubercle bacillus 
is even more pronounced than most of the other pseudotubercle 
bacilli. Inoculated into the peritoneal cavity of guinea-pigs, white 
mice, and frogs, these pseudotubercle bacilli obtained from tonsils, 
tongue, and throat produced lesions which had great similarity, micro- 
scopically, to real tubercles, but they never spread beyond these 
areas. The only difference which can be discovered is that while 



PLATE I 



FIG. 1 



FIG. 2 




MN 






Tubercle bacilli in red. 
Streptobaeilli in blue. 



Tubercle bacilli in red. 
Tissue in blue. 



X lOOO diameters. 



X llOO diameters. 



FIG. 8 



FIG. 4 



L< 









k 



Leprosy bacilli in nasal seere- Short smegma bacilli in red, 
tion of person suffering from rest of material in blue, 

nasal lesions. (Hansen.) 



X SOO diameters. 



X llOO diameters. 



(From Park's Pathogenic Microorganisms.) 



HUMAN^ BOVINE, AND AVIAN BACILLI 27 

tubercles are of a proliferative character, these pseudotubercles are 
of a more exudative and inflammatory character, showing a tendency 
to abscess formation. 

Doerr and others have also isolated acid-fast rods from the excre- 
ments of cattle, swine, sheep, guinea-pigs, white mice, chickens, dogs, 
etc. In fact, they are so frequent in the soil that any being or thing 
coming in contact with the soil is likely to have acid-alcohol-fast rods 
when carefully examined with the microscope. Doerr also found them 
in the dust in ordinary houses, in tap water, in centrifuge tubes, in 
the sediment of a laboratory flask, also in a flask of distilled water; 
finally in cerumal tartar on the teeth, and in the cerumen of the 
human ear, and also in the mouth-pieces of musical instruments. He 
found two forms which usually occur together: One a short, thick 
rod, and the other a long and thin rod, very much like the tubercle 
bacillus. Much's stain shows usually a granular structure of the rod. 

Similarly, there have been isolated microorganisms from cow's 
milk, butter, and from the surface of domestic animals, which mor- 
phologically, culturally, and even on inoculation resemble tubercle 
bacilli. The butter bacillus, first described by Petri and Rabinowitsch, 
may be mistaken for the tubercle bacillus even when inoculated into 
guinea-pigs. D. J. Davis 1 described an acid-fast streptothrix, pro- 
ducing a certain infection in the pulmonary tissues, which may be 
mistaken for tuberculosis. Microscopically, there may be difficulty 
in distinguishing them, but negative results with guinea-pigs clear up 
the case. 

It seems that the cellular structure of these pseudotubercle bacilli 
is closely related to that of the pathogenic tubercle bacilli, at any 
rate chemically, as is clearly shown by their similarity in staining 
reactions, and their effects locally when inoculated into animals. 
Some produce lesions not unlike those produced by the virulent 
tubercle bacilli, excepting that the general toxemia is lacking, and 
the lesion never spreads beyond the point of inoculation. It has also 
been found that animals sensitized to any type of the non-virulent 
acid-fast bacilli are also to some degree sensitized to the virulent form. 
But whether they are phylogenetically related, i. e., whether they 
all have evolved from a common ancestry, has not been established. 
Uhat they have not differentiated because of the variety of environ- 
ment in which they have lived for many generations is proved by the 
fact that all efforts at making them pathogenic by passage through 
the bodies of various animals for several generations have failed. 
They always remain benign in their effect on the animal organism. 
The only biological characteristics they have in common with virulent 
tubercle bacilli are: Their acid-fast properties, and their aptitude 
for causing local reactions when inoculated into animals. The tubercle 
bacilli are alone able to produce general reactions. According to 

1 Jour. Infec. Dis., 1914, xiv, 144. 



28 THE TUBERCLE BACILLI 

Kendal. Day, and Walker 1 the metabolism of the smegma and grass 
bacilli resembles that of the rapidly growing human bacilli. The 
lepra bacillus does not present this metabolic phenomenon. 

OCCURRENCE OF THE VARIOUS TYPES OF TUBERCLE 

BACILLI. 

The Human Type. — The human type is found in the vast majority 
of cases of all forms of tuberculosis in human bemgs; in adults, phthisis 
is almost exclusively caused by this virus. In spontaneous tuberculosis 
in hogs a small percentage also shows this type of bacilli, and many 
species of animals, especially those coming in contact with man, 
also are occasionally infected with human tubercle bacilli. This is 
the case with parrots and some animals in zoological gardens in cities, 
like lions, antelopes, gnu, chimpanzees, macacus rhoesus, etc., have 
been found infected with the human bacilli. The dog, rat, and mouse 
are practically immune, while the calf, rabbit, hog, and goat occupy 
intermediate positions. 

The bovine type of tubercle bacilli is responsible for disease in 
domestic animals, as cattle, sheep, goats, horses, etc. In most cases 
of tuberculosis in pigs, cats, and dogs, and in many cases in mon- 
keys, the bovine bacilli are found. 

The avian type is found hi the vast majority of tuberculous infec- 
tions in birds. Not only are fowls affected but also birds in zoological 
gardens are susceptible and are often sick as the result of infection 
with this virus. Spontaneous tuberculosis in horses, swine, monkeys, 
cattle, mice, and rats has been found, at times, to be due to this type 
of bacillus. 

Bovine Type of Bacillus Tuberculosis in Man. — Of greater impor- 
tance is the occurrence of bovine and avian infection in human beings. 
Since Koch stated the bovine bacilli were not at all identical with 
the human, and that they were not at all pathogenic to man, various 
investigations have been made with the result that Koch was, on the 
whole, not sustained. There is evidence to the effect that many 
cases of tuberculosis in human beings, especially hi children, are due 
to the bovine virus. The largest collection of cases of tuberculosis of 
various forms was published by B. Moller. 2 comprising 2048 patients. 
In adults only 2.1 per cent of bovine bacilli were found, and most 
of these were cases of abdominal and glandular disease, " digestive 
tuberculosis." In tuberculosis of the lungs only 0.51 per cent showed 
bovine bacilli. Of 186 cases of bovine infection, 145 were found in 
children under sixteen years of age, and of these, 101 had disease of 
the abdominal viscera, especially the cervical and abdominal glands. 
He also found that when bovine infection occurs in humans, it pursues 

1 Jour. Infec. Dis.. 1914. xv. 431. 

- Yerdff. Koch-Stiftung, 1916, Hefte 11 and 12. 



OCCURRENCE OF VARIOUS TYPES OF TUBERCLE BACILLI 29 

a favorable and benign course. Another collection of reported cases 
was published by Park and Krumwiede, embracing 940 instances of 
tuberculosis carefully studied as to the type of organism present, and it 
appears that in adults, sixteen years of age and over, only tuberculosis 
of the skin, abdominal organs, and general tuberculosis of alimentary 
origin may, at times, be caused by bovine bacilli. It is, however, a 
fact that but comparatively few cases have been investigated, and 
there is a lurking suspicion that in a larger series of cases the propor- 
tion would be much smaller. On the other hand, among 778 cases 
of pulmonary tuberculosis only 3, or 0.4 per cent, were found with 
bovine bacilli, showing conclusively that as regards phthisis, the bovine 
type of bacilli is not to be considered a factor in the pathogenesis of 
the disease. 

Percentage of Incidence of Bovine Tuberculosis in 940 Cases, of which 778 
were Pulmonary Tuberculosis (Park and Krumwiede). 

Adults 16 years Children 5 Children un- 

and over. to 16 years. der 5 years. 

Diagnosis. Per cent. Per cent. Per cent. 

Pulmonary tuberculosis 0.4 0.0 2.8 

Tuberculous adenitis, cervical 2.7 38.0 61.0 

Abdominal tuberculosis 20.0 53.0 58.0 

Generalized tuberculosis, alimentary origin . .14.0 57.0 47.0 

Generalized tuberculosis 0.0 16.0 8.6 

Generalized tuberculosis, including meninges, ali- 
mentary origin 0.0 0.0 66. 

Tubercular meningitis (with or without general- 
ized lesions other than preceding) .... 0.0 0.0 4.6 

Tuberculosis of bones and joints 3.3 6.8 0.0 

Tuberculosis of skin 23.0 60.0 0.0 

In children the picture is different. Under five years of age 61 per 
cent, of cervical tuberculous adenitis, 58 per cent, of abdominal tuber- 
culosis and 66 per cent, of the generalized tuberculosis and meningitis, 
and of alimentary origin, are caused by the bovine virus. 

More recent investigations have confirmed the predisposition to 
bovine infection during childhood, and the strong immunity displayed 
by adults, who are almost exclusively infected by the human type of 
bacilli. Thus, A. Stanley Griffith 1 found the following proportions of 
bovine bacilli in cases of tuberculosis of glands, bones and joints: 

Number of Per cent, of 

Age period. cases. bovine bacilli. 

to 5 years 68 27 . 9 

5 to 10 " 161 24.8 

10 to 15 "... . 86 9.3 

Over 16 " 50 6.0 

Investigations for the Local Government Board showed that 18.4 
per cent, of the children under ten years who died of tuberculosis, or 
other causes, were infected with bovine tubercle bacilli. The predi- 
lection of the glands by the bovine bacilli is also shown in the following 
figures: In a series of cervical gland cases investigated by Griffith, 2 

1 Jour. Pathol, and Bacteriol., 1916, xxi, 54. 2 Lancet, 1915, i, 1275. 



30 THE TUBERCLE BACILLI 

71.1 per cent. (20 out of 26) of the children under ten, 38.5 per cent. 
of those between ten and fifteen years, and 29.6 per cent, of persons 
over fifteen were found to have been infected with bovine tubercle 
bacilli. Mitchell 1 states that 90 per cent, of the cases of cervical gland 
tuberculosis in Edinburgh children under twelve investigated by him 
were due to bovine bacilli. 

Cobbett, 2 after a careful study. of all available evidence, arrives at 
the conclusion that "we do not yet possess the evidence which will 
enable a final verdict to be pronounced' 1 as to the significance of 
bovine infection in human tuberculosis. One thing is, however, cer- 
tain : In adults fatal bovine infection, if it does occur at all, is so rare 
that it is of no significance from any standpoint. Indeed, only in 
children under five years of age are bacilli of bovine origin apt to cause 
disease. 

Virulence of Bovine Bacilli in Human Beings. — There appears to be 
some good and valid evidence to the effect that when a human being 
is infected with bovine tubercle bacilli, the disease produced is likely 
to run a favorable, and even a benign, course; only rarely is death 
caused by these microorganisms. We know that it is the pulmonary 
form of tuberculosis which is fatal; while tuberculosis of the glands, 
joints, and bones is curable in the vast majority of cases. Similarly, 
tuberculosis of the serous membranes, notably the peritoneum, often 
shows a tendency to recovery. We will see later on in this book that 
this is also true to a certain extent about the pleura. The meninges 
are an exception for obvious reasons. Xow, the peritoneum is very 
frequently affected with bovine tubercle. Moreover, tuberculosis of 
the cervical and thoracic glands is very common among children, yet 
the mortality among them is very low — tuberculosis kills less between 
three and twelve than at any other age period. Moreover, it has been 
found that in many eases caseous tissue obtained from tuberculous 
glands, while showing the presence of acid-fast rods, fails to infect 
animals when they are inoculated. It has thus been suggested that 
these mild bovine infections of the cervical, mesenteric and thoracic 
glands, while in themselves harmless, nevertheless confer immunity 
to the organism which may last for life and for that reason adults are 
safe against infestion by human tubercle bacilli. This point will be 
again discussed later on. 



POISONS PRODUCED BY THE TUBERCLE BACILLI. 

When tubercle bacilli enter the human body they do harm in 
various ways. Locally, they destroy the tissues in which they have 
settled, producing coagulation necrosis, etc., which will be discussed 
later on, By their proliferation they also produce general disturb- 

1 British Med, Jour., 1914, i, 125. 

2 The Causes of Tuberculosis, London, 1917, p. 657. 



POISONS PRODUCED BY THE TUBERCLE BACILLI 31 

ances in the functions of the invaded body which can only be explained 
as caused by some poison liberated by the bacilli. The nature of these 
poisons is obscure at present, although strong efforts have been made 
to ascertain all the facts in this respect. 

When dead tubercle bacilli are injected subcutaneously into the 
healthy animal, a distinct inflammation is produced at the site of the 
inoculation, frequently followed by suppuration. It is immaterial 
whether the bacteria have been killed by chemicals or by heat, the 
result is the same in either case. When dead tubercle bacilli are 
injected intravenously into rabbits, provided a sufficient quantity 
is employed for the purpose, a proliferation of tissue in the lung is 
produced similar to that of tubercle, containing, as it does, giant 
cells which may caseate. After intratracheal insufflation, tuberculous 
nodules with epithelioid and giant cells are produced. 

On the other hand, when fluids containing the products of the metab- 
olism of tubercle bacilli are injected in very large doses into normal 
and healthy animals, no toxic effects are produced. 

These and other facts tend to show that the effects of the bacilli 
on the animal body are not due to mechanical irritation produced 
at the site of the inoculation, but are the result of the liberation of 
toxic matter which acts both locally, producing coagulation necrosis, 
and generally, producing fever, etc. We know this, but all attempts 
to isolate a true toxin from tubercle bacilli have utterly failed, and 
with the intensive studies that have been made during the past thirty 
years along these lines, we have not yet been able to clearly define 
the tuberculous poisons. They appear to be part and parcel of the 
living protoplasm of the tubercle bacilli, and are liberated only after 
the latter have been destroyed. In other words, the tubercle bacilli 
belong to a group of microorganisms which do not secrete soluble 
toxins, but nevertheless produce general effects on the body which 
they invade; their deleterious effects are the result of the action of 
endotoxins. 

Tuberculin. — Koch was the first to discover that when dead tubercle 
bacilli are injected in large quantities into tuberculous animals, death 
is caused; when small doses are injected, only a slight reaction is 
caused at the site of the inoculation, which soon heals. On repeated 
inoculations he observed improvement in the condition of the sick 
animal. On these experimental findings he based his suggestion for 
the use of tuberculin as a diagnostic and therapeutic agent in tuber- 
culosis. 

Tuberculin consists mainly of the culture fluid in which the bacilli 
have grown, of disintegrated bacilli or extracts of their protoplasm, 
or both. As originally prepared by Koch, the following process is 
pursued : 

Tubercle bacilli are cultivated on bouillon made from fresh veal 
to which 1 per cent, of dried peptone, 0.5 per cent, of sodium chloride, 
and 5 per cent, of glycerin are added. Within six to eight weeks of 



:;l> the tubercle bacilli 

luxuriant growth at 38° C. the culture is poured into an evaporating 
dish, placed on a water bath and evaporated to one-tenth the original 
volume, and any remains of bacilli are removed by filtration; con- 
taining 50 per cent, of glycerin, the resulting preparation is quite 
stable. 

It is thus clear that tuberculin is not a true toxin, nor is it a pure 
endotoxin; but a 50 per cent, glycerin solution of the products of 
macerated tubercle bacilli in the culture fluid which are not destroyed 
by heat, and also any portion of bacilli which remains in the solution, 
or both. 

Ever since the introduction of this original tuberculin, many other 
methods of preparation have been devised by Koch himself and others, 
but all have shown that the active principle is practically the same. 

The Action of Tuberculin. — There are differences of opinion as to 
whether tuberculin depends in its action on a certain chemical prin- 
ciple, or on several chemical substances. In fact, the chemical com- 
position of this preparation is obscure. Some have suggested that the 
active principle is a proteid or albumose. Klebs, Levene, and others 
believe that they have isolated various active principles; some have 
even obtained typical tuberculin reactions with these substances. 
But, as will be shown when discussing the tuberculin reaction, any 
protein inoculated into a tuberculous individual produces practically 
the same effects — tuberculosis being invariably accompanied by an 
altered reactivity to these substances. It can be said emphatically 
that, at the present state of our knowledge, we are in the dark as to 
the active principle of tuberculin. 

Healthy animals bear the injection of tuberculin in large doses 
without any harm; the same is true of healthy human beings. Koch 
injected into his own body 0.25 c.c. of tuberculin and suffered from a 
severe reaction; after his death an autopsy showed that he had suf- 
fered from extensive pulmonary tuberculosis. On the other hand, 
Hamburger administered as much as 500 mgs. of tuberculin into 
non-tuberculous infants and children without producing the slightest 
local, or general, reaction. Clinical experience among human beings, 
as well as in cattle — in which it is easy and feasible to determine by 
autopsy whether there are tuberculous lesions — has shown that a 
reaction after a large dose of tuberculin in an apparently healthy 
person is conclusive proof of an existing tuberculous lesion some- 
where in the body. We shall show later on that this is true of the 
vast majority of people in civilized communities, and therefore reac- 
tions to large doses of tuberculin are of very little value to the clinician 
who looks for active tuberculosis. 

The reason why tuberculin is harmless in healthy organisms, and 
produces such a pronounced reaction when injected into tuberculous 
organisms, is not clear. Various theories have been advanced to 
explain it. The most widely accepted explanation is that of Wolff- 
Eisner. He assumes that tuberculous infection produces specific anti- 



POISOXS PRODUCED BY THE TUBERCLE BACILLI 33 

bodies in the tissues which break down the tuberculin molecule, just 
as the digestive enzymes break down certain albumin molecules pro- 
ducing innocuous, and highly poisonous, albumoses. The antibody 
which acts in this manner he calls tuberculolysin. In non-tuberculous 
organisms there is no tuberculolysin, and when tuberculin is injected 
it circulates within the juices, producing no toxic effects, and is finally 
eliminated, like other harmless foreign proteins. In the tuberculous 
organism the tuberculin comes in contact with the lysin, breaks it 
up, and liberates a toxic substance which produces the reaction. 

Phenomena of Hypersensitiveness. — When a rabbit is infected with 
tubercle bacilli, and four weeks later 0.1 to 0.3 c.c. of tuberculin is 
injected subcutaneously, the animal succumbs within six to twenty- 
four hours. Koch found that in animals infected eight to ten weeks 
previously 0.01 c.c. of tuberculin is sufficient to cause death. Injec- 
tions of very small doses into tuberculous animals produce only a more 
or less severe reaction — fever, loss of weight, etc. This is obtained 
with injections of either living or dead tubercle bacilli. 

When repeated small doses of tuberculin are injected, certain 
phenomena are observed which are not unlike those obtained after 
the injection of other foreign protein substances into an animal. 
The tuberculin reaction is evidently a manifestation of tuberculo- 
protein hypersensitiveness. Some authors have, indeed, been inclined 
to ascribe the reaction to tuberculin to the action of the non-specific 
substances, glycerin, proteins, extractives, etc., contained in the tuber- 
culin, and have argued that the reactions to repeated inoculations 
are anaphylactic phenomena. Perhaps the fact that the usual dose 
of tuberculin does not contain enough of foreign proteins disproves 
this contention, and shows that there must be some specific substances 
which are active in this regard. But this has not been proved con- 
clusively. 

Theoretically, it would be expected that tuberculin, provoking the 
same phenomena in the animal body as the living tubercle bacilli, 
should also have an immunizing effect. But so far nobody has been 
successful in an attempt at immunization of the body with dead 
tubercle bacilli, or any part of the culture in which they grow. More 
satisfactory results have been obtained infecting animals with living- 
bacilli. 

Tuberculin hypersensitiveness differs from anaphylaxis by the fact 
that in normal animals tuberculin may be injected in large or small 
amounts, at long or short intervals without producing hypersensi- 
tiveness, and attempts at passive transference of tuberculin hyper- 
sensitiveness have led to doubtful results. Baldwin has been unable 
to produce transference, or passive anaphylaxis, from tuberculous 
guinea-pigs to healthy ones, and also from rabbit to rabbit, and from 
rabbit to guinea-pig. From human to guinea-pig the results were very 
doubtful, but to rabbit, partly successful. But another difference 
between anaphylactic shock and tuberculin hypersensitiveness may 
3 



34 THE TUBERCLE BACILLI 

be mentioned. The former phenomenon appears immediately after 
an injection, while in the latter they are delayed for many hours; in 
the former there is a marked reduction in the temperature, etc., while 
in the latter the contrary is true. 

Specificity of the Tuberculin Reaction. — We have seen that tuber- 
culin produces obvious effects only in the infected organism. The 
question then arises whether the reaction it produces is strictly specific. 
Many workers have found that tuberculous animals react to, and may 
even be killed by, the injection of any foreign bacterial protein of non- 
tuberculous origin in the same manner as by tuberculin. In human 
beings there was also found hypersensitiveness to non-tuberculous 
extracts from bacilli closely resembling the hypersensitiveness induced 
by tuberculin. Even the cutaneous tuberculin reaction can be pro- 
duced by non-tuberculous toxins inoculated in the same manner as 
tuberculin is applied in the von Pirquet and other tests. 

The changes in reactivity to tuberculin may be induced by non- 
tuberculous proteins and toxins. The general reaction, the fever, with 
concomitant subjective symptoms, such as headache, anorexia, etc., 
also the local reaction at the site of the inoculation, and finally even 
the so-called " focal reaction" manifesting itself in the tuberculous 
lesion, have all been produced by non-tuberculous substances. On 
the other hand, tuberculin had produced these reactions in patients 
suffering from leprosy, syphilis, etc. The suggestion that this does 
not militate against the specificity of the tuberculin reaction, because 
these diseases may be combined with tuberculosis, does not explain 
every case. 

It has also been found by Mettetal, 1 and others, that individuals 
who react to tuberculin also react in almost the same fashion to saline 
solutions, which would indicate that it is not necessarily the specific 
bodies in the tuberculin which are responsible for the fever, malaise, 
etc. At any rate, tuberculin is not the only substance that produces 
these phenomena in tuberculous individuals. 

Autopsy control has not cleared up the problem. There have been 
reported cases in which a positive reaction was obtained during life, 
but no tuberculous lesions could be discovered on careful dissection 
of the body after death, and the reverse. In cattle it was found that 
only 85 to 90 per cent, of those reacting to tuberculin show tuberculous 
changes on dissection after slaughter, while 10 per cent, of those which 
do not react show tuberculous changes in some organs. These facts 
have important bearings on the problems presented by tuberculin as 
a diagnostic agent and will be more fully discussed later on. 

Another problem arises when changed reactivity to tuberculin is 
found. Does it invariably indicate that the body is at the time har- 
boring living and virulent tubercle bacilli? Do individuals who have 

1 Valeur de la tuberculine dans la diagnostic de la tuberculose de la premiere enfance, 
These de Paris, 1900. 



POISONS PRODUCED BY THE TUBERCLE BACILLI 35 

at one time passed through a tuberculous infection, but in whom 
the lesion has completely cicatrized, also show hypersensitiveness to 
tuberculin? To the first question we have a positive answer — many 
healed, cicatrized and calcified tuberculous lesions have been found 
to harbor virulent bacilli, as has been proved experimentally. These 
bacilli are in fact responsible for acute exacerbations observed in quies- 
cent and latent tuberculosis; they may also be held responsible for 
the onset of the average case of phthisis in adults, as will be, shown 
elsewhere. But what is of more importance is whether, once acquired, 
the tuberculin hyoersensitiveness remains throughout the life of the 
individual. This is a problem which has not yet been investigated 
to an extent as to warrant a positive answer. 

Outside of these theoretical considerations, these problems have 
great practical bearings on the utility of tuberculin as a diagnostic 
agent, which is discussed on page 340. 

Mixed Infection. — Soon after the discovery of the tubercle bacilli, 
some investigators, finding other pathogenic microorganisms in the 
secretions and excretions of phthisical subjects, have maintained that 
the disease is due to infection with other bacteria in addition to the 
specific germ. In fact, many authors of ten or fifteen years ago, like 
Cornet, Petruschky, Maragliano and others, maintained that the fever 
in tuberculosis is more the result of infection with pyogenic organisms 
than with the tubercle bacilli. The fact that contents of cavities, as 
well as their walls, which are often covered with pyogenic membranes 
often contain influenza bacilli, pneumococci, streptococci, staphylo- 
cocci, etc., would tend to confirm this view. This view is even now held 
by many authorities. Thus, Victor C. Vaughan says: "Unaided, the 
tubercle bacillus seldom kills, but the microbic tissues caused by its 
growth form a suitable medium for the lodgment and growth of other 
bacteria, and tuberculosis usually terminates as the result of infection. 
So long as the infection is unmixed, the progress of the disease is slow." 
But in acute miliary tuberculosis, which is invariably fatal, only the 
specific microorganism is found. On the other hand, many advanced 
cases of phthisis, with large cavities, and sputum containing pyogenic 
microorganisms in addition to the tubercle bacilli, have no fever, 
nightsweats, anorexia, emaciation, etc. 

It must, however, be emphasized that when microorganisms other 
than the tubercle bacilli are detected in the sputum, or the contents 
of cavities, it does not prove that they are responsible for any of the 
symptoms observed in the patient. It is also a fact that microorgan- 
isms discovered in the sputum may not come from the diseased focus 
in the lung. They may be derived altogether from the upper respira- 
tory passages or the mouth. It is also very difficult to find them by 
culturing. A medium must be employed which is suitable both for 
tubercle bacilli, and other microorganisms. While egg albumin has 
been used for this purpose, it is notalways satisfactory. Koch-Kitasato 
has suggested certain methods for the purpose, and recently Hall and 



;». THE TUBERCLE BACILLI 

Harvey 1 suggested a modification, which is more satisfactory. They 
thus isolated the Streptococcus non-hemolyticus as the most frequent 
pyogenic organism found in association with pulmonary tuberculosis. 
In addition, staphylococci and diploccocci were found, but not in 
abundance. 

Recent investigations have proved conclusively that the fever in 
tuberculosis may be produced solely by the tubercle bacilli; indeed, 
an injection of tuberculin produces fever. The hectic fever of advanced 
phthisis, which bears great similarity to septic fever due to other 
causes, may also be the result of pure tuberculous activity. Even 
Inman, who through very laborious research found a secondary infec- 
tion in all cases with fever while the patient was resting in bed, con- 
cludes that the tubercle bacillus is almost invariably the predominant 
infective agent. 

During the course of phthisis secondary infections are often observed. 
A phthisical patient may be infected with pneumococci which produce 
pneumonia, influenza bacilli, producing grippe, etc. But this can be 
no more considered " mixed infection" than the association of phthisis 
with diphtheria, gonorrhea, etc. 

The streptococci, staphylococci, pnemnococci, etc., which are often 
found in tuberculous cavities may, and often do, influence the symp- 
tomatology, course, and termination of the disease, but in incipient 
cases the microorganism which is responsible for the disease is only 
the tubercle bacillus. 

1 Jcur. Med. Research, 1917, xxxv, 265. 



CHAPTER II. 
TUBERCULOUS INFECTION. 

The Problems of Infection. — With the discovery of the tubercle 
bacillus in 1882 it was at once concluded that practically all the 
problems of phthisiogenesis had been settled. The infective agent, 
the bacillus, enters the human body, implants itself in some tissue; 
by its growth and metabolic processes it produces toxic symptoms 
and, causing caseation and liquefaction, destroys vital organs, etc. 
With this knowledge, it was thought that the prevention of the disease 
had been reduced to simple principles: The destruction of the bacilli 
wherever found and the prevention of their entry into the human 
body, when attempts at their destruction fail for any reason. 

To destroy the bacilli it was necessary to ascertain all the places 
where they are found in Nature. This was apparently an easy matter, 
We know that the tubercle bacillus is a strict parasite, living and 
multiplying only in the human and animal body. Investigations by 
Sander tend to show that, within certain limits, they can proliferate 
on vegetable media during the hot summer months, but it is problem- 
atical whether this mode of life explains any infection in man. After 
the facts gathered in investigations are taken into consideration, 
there is no doubt that the only suitable soil for life, growth and multi- 
plication for this bacillus is the animal body, and that the secretions 
and excretions, of diseased persons and animals are the only means 
of disseminating the disease. 

W 7 e have shown that bacteriologists have distinguished at least 
four main types of pathogenic tubercle bacilli : the human, the bovine, 
the avian, and the reptilian. Practical experience has shown that the 
last two types, those of birds and of cold-blooded animals, play no 
role in the epidemiology of tuberculosis in human beings, at least 
not a very significant role. There are consequently left the human 
and bovine types to be considered as etiologically important in tuber- 
culosis in human beings. 

Careful investigations by Theobald Smith, William H. Park, A. S. 
Griffith, Fraser, The British Royal Commission, The German Imperial 
Health Board, and others have shown that more than 99 per cent, of 
phthisis in adults, and about 85 to 90 per cent, of serious tuberculous 
disease in children are due to the human type of bacillus; that the 
bovine type is found in about 10 per cent, of tuberculosis in children, 
and in phthisis this type is so exceptional as to make each case worthy 
of careful reporting. It also appears from the evidence thus far 



38 TUBERCULOUS INFECTION 

gathered that tuberculosis in children due to bovine bacilli is mostly 
of the milder forms of the disease — surgical tuberculosis, of the gland- 
ular systems, especially of the thoracic and the abdominal glands, of 
the joints, bones, and skin. In other words, the tuberculosis caused 
by the ingestion of bacilli with milk from tuberculous cows is not of 
great significance, except perhaps in infants, when compared with the 
immensity of the problems presented by infections with the human 
type of bacilli causing phthisis in adults, and most cases of fatal 
tuberculosis in infants. 

For these reasons, some authors have stated that bovine infections 
may be disregarded; only infection with bacilli acquired through the 
entry of tubercle bacilli which have been incubated, so to say, in 
tuberculous human beings, is to be combated, if phthisis is to be eradi- 
cated at all. The corollary to be drawn is that the sources of the 
tubercle bacilli are mainly human consumptives. 

Mutation of the Types of Bacilli. — Further study has, however, 
complicated this problem. It has been suggested by many authors, 
notably Orth, 1 Rabinowitsch, Beitzke, Much, and others, that bovine 
bacilli, remaining in the human body for a long time, and adapting 
themselves to the surroundings, may acquire the characteristics of the 
human type, a kind of biological transformation of type, or mutation. 
It is clear that in our attempts at eradication of phthisis this problem 
is of immense importance. The 10 per cent., or more, of children in 
civilized countries who are infected during childhood with milder 
forms of tuberculosis thus harbor the bovine bacilli within their 
bodies for many years, during which time they adapt themselves to 
the surroundings within the human body, and when they cause phthisis 
in the adult we find them with the characteristics of the human type. 

In support of this assertion it was shown that very often "atypical" 
bacilli are found in cases of tuberculosis; they are microorganisms 
which cannot be classed with either the human, or the bovine type. 
They have been called "transitional" types; types which may have 
been originally bovine, but after sojourning in the human body for 
some time, are on the way to acquiring traits of human bacilli. 

The British Royal Commission says in this connection that they 
"are inclined to regard transmutation of the bacillary type as exceed- 
ingly difficult, if not impracticable, of accomplishment by laboratory 
procedure; though in view of certain instances in which we obtained 
from one and the same human body both types of bacillus, we are not 
prepared to deny that transmutation of one type into another may 
occur in Nature." "Direct experiment has not succeeded in proving 
that a tubercle bacillus of given type can be transformed into one of 
another type by being made to reside in the body of a new host in 
which tuberculosis, when it occurs naturally, is caused by the latter 
type of bacillus," says Cobbett. 2 Arloing, 2 Marcus, Rabinowitsch, 

1 Drei Yortrage liber Tuberkulose, Berlin, 1913. 

2 The Causes of Tuberculosis, London, 1917, p. 368. 



MUTATION OF THE TYPES OF BACILLI 39 

Sorgo, Musemeier, Dammann, and others claim to have been able to 
produce changes in the morphological and cultural characters, and in 
the virulence of bacilli by passage through various animals, or culti- 
vating them in different media. But Park and Krumwiede 1 say: 
"We have carefully examined the reports of numerous workers on this 
point, and cannot admit that the evidence for the transformation of 
type is complete." Theobald Smith, after studying the evidence, also 
arrives at the conclusion that "in general the results of these passages 
have been negative, so far as any recognizable modification of type is 
concerned." Park's suggestion that the change in type observed after 
passing through a series of animals is due to additional bovine infection 
has a great deal in its favor. As has been shown by Cobbett, 2 the more 
the conditions for carrying out such researches are made to approach 
the ideal, the rarer become the instances of apparent modification of 
type. Cases in which both types were found in human beings have been 
reported. 

We are therefore justified in concluding with Park and Krumwiede 
that "the two types are probably different, due to residence in different 
hosts over long periods of time, and as such are stable. The evidence 
of rapid change is incomplete and inconclusive." In the human 
disease the stability of type is apparently beyond question. Some 
cases have been followed for long years and the type of the bacillus 
has been found to be unaltered. Weber and Steffenhagan have followed 
for ten and a half years a case of surgical tuberculosis and always 
found bovine bacilli, without changing their typical characteristics. 

However, the weight of evidence is in agreement with Cobbett 3 
to the effect that if transformation of type does not occur in our 
laboratory experiments which, prolong them how we will, are neces- 
sarily limited in time, it does not follow that an exceedingly slow modi- 
fication of type does not take place when a suitable change of host 
occurs, as for example when bovine tubercle bacilli take up their resi- 
dence for several generations in man, pig, or horse. Such a change is 
perhaps dimly indicated in some of the experiments with viruses of the 
bovine type taken from these species. This slow alteration which ap- 
pears probable (though the actual evidence for its existence is very 
slender) is, if it occurs at all, of a magnitude altogether different from 
that of the more or less sudden and complete changes of type which 
have appeared in some of the passage experiments. But such slow 
changes hinted at here are of little more than theoretical importance. 

The weight of evidence is thus in favor of human phthisis being 
due almost exclusively to human bacilli, and that infection during 
childhood with bovine bacilli cannot be held responsible for phthisis 
in the adult, because it has not been proved that mutation of one 
type into another takes place. 

1 Tr. Sixth Ann. Meet. Nat. Assn., Study and Prevent. Tuberc, 1910, p. 332; Jour. 
Med. Research, 1911, xx, 313; 1912, xxii, 109. 

2 Loc. cit., p. 367. 3 Ibid., p. 369. 



40 TUBERCULOUS INFECTION 

The source of the bacilli causing phthisis in the adult, and serious or 
fatal tuberculosis in infants or children, appears to be the tuberculous 
man who expectorates myriads of bacilli fit for entering healthy persons 
and causing disease. 

The Channels of Entry of the Tubercle Bacilli. — It is obvious that 
in order to prevent phthisis, the ways in which the bacilli enter the 
human body must be known definitely. To the average person, 
lay or medical, who has informed himself from current popular litera- 
ture, this question has been answered satisfactorily: If the bacilli 
are derived from human sources, they have usually been inhaled; if 
from bovine sources they have been ingested. 

But it may be stated without fear of meeting contradiction from 
competent sources that this problem has not yet been solved to the 
satisfaction of all who are entitled to an opinion. R timer, 1 one of the 
most active experimental workers in the field of tuberculosis, and 
one of those best qualified to speak, says that none of the given channels 
of entry of the tubercle bacilli is alone sufficient to adequately solve all 
the problems presented by tuberculous infection. 

There are three evident portals of entry which are always mentioned 
as possible: (1) In h a lotion through the respiratory passages; (2) in- 
gestion through the digestive tract; (3) inoculation into the skin or 
mucous membranes. While each of the three modes of infection has 
been shown to be possible, and proved experimentally and clinically, 
the inhalation channel has been considered by many authors the most 
important in the case of human phthisis. Ingestion may, however, 
be found of greater importance than it is now considered. 

Contact Infection. — The inoculation of the tuberculous virus into 
the skin and mucous membranes may cause disease. This has been 
proved beyond any doubt both experimentally and clinically. In- 
oculated tuberculosis is most virulent during infancy; the younger 
the child, the more serious the outcome. The "pathologist's wart" 
and the "butcher's wart" in the adult are not very malignant diseases, 
while infection of the wound during ritual circumcision of Jewish in- 
fants is almost invariably fatal. The reasons for these differences in 
virulence will be discussed later on. 

Sputum from tuberculous patients is infective in another way: 
It enters the circulation through an abrasion. In overcrowded and 
filthy homes, where children creep around on the floors on which 
consumptives have expectorated, this mode of infection is undoubtedly 
quite frequent. Baldwin 2 and others found virulent tubercle bacilli 
on the fingers, and under the nails of consumptives, as well as of 
those who live with them. It has also been established that under 
exceptional circumstances infection is possible through the unbroken 
skin of animals. 

Skin infections produce local lesions at the point of entry of the 

1 In Brauer, Schroder, and Blumenfeld's Handbuch der Tuberkulose, 1914, i, 247. 

2 Tr. Am. Climat. Assn., 1908, xiv, 202. 



INFECTION BY INHALATION OF THE BACILLI 41 

bacilli, and in infancy a fatal bacteremia may be the result. But when 
cutaneous skin affections such as lupus vulgaris, tuberculosis verru- 
cosa cutis, or the so-called tuberculides are considered, it must not 
be hastily concluded that they have invariably been acquired by local 
infection. As will be shown later on, while discussing the aerogenic and 
hematogenic origin of tuberculosis, the bacilli may have been brought 
to the skin by the blood stream. This has, in fact, been found true 
in most cases. It is noteworthy in this connection that phthisis occurs 
only exceedingly rarely in patients with lupus and other tuberculous 
skin affections. Some have spoken of an immunity against tubercu- 
losis possessed by these patients. The reverse also appears to be true — 
tuberculous skin disease is rare in phthisical patients and, when we 
bear in mind the opportunities for infection, we are justified in speak- 
ing of immunity. 

On the whole it appears that Romer is on a sound foundation when 
he says that the problem of infection through the skin has not yet 
been studied sufficiently, and with our present knowledge we are 
not in a position to state with any degree of certainty its importance 
as a factor in the spread of the disease. 

Infection by Inhalation of the Bacilli. — That the virus of tubercu- 
losis is inhaled with the inspired air has been asserted for centuries 
by physicians, and Villemin suggested this mode of infection after 
his experimental investigations. But Koch and his pupil Cornet 1 
were the first to prove that dust containing tubercle bacilli derived 
from desiccated sputum is highly infectious to guinea-pigs. Cornet's 
experiment with dried sputum scattered over a carpet on which the 
animals were compelled to live while the carpet was often swept with 
a stiff broom, has remained classical, and is often quoted as proving 
conclusively the dangers lurking in dried sputum in the average dwell- 
ing inhabited by careless consumptives. On the basis of such experi- 
ments rested the entire inhalation hypothesis of tuberculous infection. 

The fact that diffuse daylight, especially sun-rays, kills tubercle 
bacilli, and soon renders them avirulent, would largely exclude infec- 
tion through sputum deposited in the street and even in large, bright 
sunny rooms. But the average consumptive, derived as he is from 
the poorer strata of population, and living in a squalid dwelling, lack- 
ing sufficient light, may deposit sputum which retains its virulence for 
a long time. 

Many valid objections have been raised against the theory that 
desiccated tuberculous sputum is the main source of infection in man. 
Flugge 2 and many others have shown that in the ordinary course 
of human events things are not as simple as stated by Cornet and 
Koch. The experiments with the carpet are not altogether analogous 
to the conditions found in human dwellings, and by no means prove 
that infection is acquired mainly through the inhalation of dust laden 

i Verhandl. Berl. med. Gesellsch., 1899, xxx, 91. 

2 Ztschr. f. Hyg. u. Infectionskrankh., 1909, xxx, 107. 



L> TUBERCULOUS INFECTION 

with dried tuberculous sputum. Such large quantities of sputum as 
were used by Cornet in his experiments on guinea-pigs are exceedingly 
rarely, it' ever, found in the most squalid of dwellings. It is also 
doubtful whether dust laden with' virulent tubercle bacilli is often 
raised to the height of the human head to be inhaled in sufficient 
amount to infect, even while the floor is being swept. 

In fact, further investigations' by Fliigge, Xeisser, Kohlisch, and 
others have not yielded the same results as those reported by Koch, 
Cornet, and their followers. It was found that in houses inhabited 
by consumptives the sputum deposited on the floors is not often 
perfectly dried and thinly pulverized, capable of rising with the dust 
to the height of five or more feet from the ground. Moreover, con- 
ditions in unsanitary homes are not conductive in the direction of 
drying the sputum soon after it has been eliminated by the consump- 
tive. And if it takes time to dry, it must be remembered that the 
bacilli lose their virulence w T ithin ten days, owing to putrefactive pro- 
cesses on the floors of filthy houses, and the diffuse light which acts 
during the day, or artificially, during the night. It is also noteworthy 
in this connection that in the average house there are no air currents 
strong enough to raise the dust to the height of about five feet. 

It may seem incredible, yet it is a fact that it is exceedingly rare 
to find a house where proper precautions are taken as to expectoration 
in which the collected dust shows virulent tubercle bacilli. Even in 
houses inhabited or frequented by consumptives — sanatoriums, dis- 
pensaries, railroad stations, factories, cars, etc. — no dust containing 
virulent tubercle bacilli has been found in most cases investigated. 
Thus, Kohlisch 1 could not infect^ guinea-pigs, which are very suscepti- 
ble, with dust collected in houses inhabited by consiunptives : Wagner 
collected dust in a sanatorium at Zurich, in such places in w T hich the air 
stream could have dispersed it, and injected it intraperitoneally into 
guinea-pigs and found that in only 3.5 per cent, of cases did infection 
take place. Even in Chausse's 2 investigations of the dust in the tuber- 
culosis wards of the Hospital Boucicaut in Paris, w T here conditions are 
such as to favor bacterial life, only seven out of eighteen specimens 
showed the presence of virulent bacilli. Dust collected in the streets 
hardly ever shows the presence of living tubercle bacilli. 

Infection under ' 'Natural' ' Conditions. — In a review of the literature 
on this subject, Charles V. Chapin 3 says: "Although there has been a 
vast amount of experimental work on infection in tuberculosis, there 
has been very little in which conditions at all approached the natural. 
Usually there is an excessive amount of exposure, or an excessive 
number of germs in spray or dust. Thus, in Cornet's notable experi- 
ment, where 47 of 48 guinea-pigs were infected by breathing dust, 
the carpet had been smeared with large quantities of sputum, and it 

1 Ztschr. f. Hyg. u. Infectionskrankh., 1908, lx, 508. 

2 Ann. Inst. Pasteur, 1914, xxviii, 720, 771. 

3 The Sources and Modes of Infection, p. 309. 



DROPLET INFECTION 43 

was forcibly beaten so that clouds of dust rose up directly in front of 
the animal. It is surprising that so few have thought it worth while 
to see how infection takes place in animals kept under conditions 
as nearly as possible like those under which human beings live." 

At Dr. Chapin's suggestion, M. S. Packard carried out an experi- 
ment with a view of determining the mode of infection under "natural 
conditions." Two sets of guinea-pigs were exposed in a house occupied 
by a careless consumptive. They were exposed in cages, one set fed 
by the patient, and the other excluded from any possible form of 
contact. Most of the animals in both sets developed tuberculosis. 
Chapin suggests that the animals kept in the locked cage covered 
with wire gauze were infected by mouth spray, as the patient often 
held his face right in front of the box and talked to the animals. 

Other experiments along these lines were performed by Schroeder 
and Cotton. 1 They exposed 7 cows in adjoining stalls to 3 tuberculous 
cows, and found that 6 contracted the disease. They exposed 100 
guinea-pigs in the stalls, 50 in cages below the mangers where food 
could sift through from the mangers, and 50 on the walls. They 
also exposed 35 guinea-pigs for one hundred and thirty-five days on 
the walls of the stalls. Only 2 developed tuberculosis. Of 42 animals 
kept for fifty-one days under the manger of infected cows, 6 developed 
tuberculosis of an acute and general type. 

There are some points to be borne in mind when evaluating the 
bearings of these experiments on spontaneous human infection. 
Guinea-pigs and cattle are more susceptible to infection with tubercle 
bacilli than are humans and, after all, the experiments were not alto- 
gether in conformity with conditions in human dwellings. Even 
Bartel and Spieler's, 2 and other attempts, to simulate conditions in 
human contact of tuberculous with non-tuberculous fail, when critically 
examined. It is also a fact that cattle, guinea-pigs, and other animals, 
are "virgin soil," while human beings above the age of fifteen have 
mostly been immunized by a previous mild infection. Virgin soil is 
easily infected, as was repeatedly shown. There are many cases 
on record in which cows, in whom the only manifestation of tuber- 
culous infection was that they were "reactors," were introduced into 
stables with other cows which did not react to tuberculin. The latter 
were soon infected, becoming "reactors," though, so far as could be 
ascertained, the first infected cows did not excrete any tubercle bacilli. 
This would indicate that infection can be accomplished in some 
manner with which we are as yet unacquainted. 

Droplet' Infection. — It is obvious that though infection through 
the inhalation of dust containing desiccated tuberculous sputum is 
undoubtedly possible, this is not the only, or the most common, mode 
of spontaneous infection of human beings under "natural conditions," 

1 Report of Bureau of Animal Industry, 1906, xxiii, 31. 

2 Wiener klin. Wchnschr., 1905, xviii, 218. 



I 1 TUBERCULOUS INFECTION 

and many have maintained that in the vast majority of cases infec- 
tion is accomplished directly from one person to another. The moist 
droplets eliminated by consumptives while speaking, and especially 
while coughing and sneezing, may be inhaled by persons who happen 
to be in their proximity. Fliigge 1 and his followers, who have done 
considerable experimental work along these lines, are satisfied that 
under natural conditions the dissemination of tuberculosis from man 
to man, "droplet infection," is the most common mode. 

Careful research has shown that the air exhaled by consumptives 
during ordinary and quiet breathing is free from tubercle bacilli, 
but the moist droplets eliminated from the mouth while talking, 
coughing, sneezing, etc., do often contain tubercle bacilli which may 
remain floating in the air for some time. Indeed, it has been found 
that the Bacillus prodigiosus may thus float in the air for five hours. 
But this will hardly hold for the tubercle bacillus. After holding a 
cover-glass in front of a coughing consumptive, tubercle bacilli were 
found microscopically, as well as by inoculation experiments which 
were positive in 90 per cent, of cases. In many cases bacilli were 
deposited on cover-glasses which were held at a distance of from 40 to 
80 cm. from the patient's mouth. The infectiousness of these droplets 
was confirmed by experiments of Heymann, 2 who exposed guinea-pigs 
in front of coughing consumptives. 

The most conclusive proof that droplets may carry bacteria has been 
furnished by Laschtschenko. 3 In various parts of a large hall he placed 
Petri dishes containing culture media. He then washed his mouth with 
a suspension of bacillus prodigiosus, a microorganism which is not found 
naturally in the air, and which may be easily identified. After deliver- 
ing a speech, he proceeded to collect the dishes and placed them in an 
incubator. Many of the culture media in the dishes showed excellent 
growth of the bacteria. Gordon 4 repeated this experiment and obtained 
the same results. 

These experiments were apparently more often positive than in the 
case of experimental infection with dust containing desiccated tuber- 
culous sputum, and Fliigge and his followers conclude that this mode 
of infection is the most important under natural conditions. 

But even these experiments are open to question. The animals 
were held tightly for hours, directly exposed to the faces of the con- 
sumptives who coughed directly into their open mouths. Such ex- 
posure never occurs in human beings, except perhaps in cases of tu- 
berculous mothers holding their crying babies on their arms, and 
coughing directly into their open mouths, which may be observed 

1 Die Verbreitungsweise und Bekampfung der Tuberkulose auf Grand experimenteller 
Untersuchungen, Leipzig, 1908. 

2 Quoted from Fliigge. 

3 Ztschr. f. Hyg., 1899, xxx, 125. 

4 Suppl. Ann. Report Med. Off. Loc. Govt. Board, 1902-3, p. 425. 



NATURAL BARRIERS AGAINST INHALATION INFECTION 45 

now and then among certain classes, but after all cannot be considered 
very common. 

Even conceding that droplet infection is an important mode of 
transmission of tuberculosis, it must be realized that it depends on 
many factors which are not always, nor even often, operative. It 
has been found that when a healthy person is at a distance of three 
feet from the coughing patient, the droplets will not reach far enough 
to become a possible infective agent, excepting perhaps when carried 
by air currents. Another important factor is the dose of the bacilli 
that may thus be inhaled. As has been shown elsewhere, small num- 
bers of bacilli are easily taken care of by the human organism. It is 
also a fact that tubercle bacilli thus eliminated do not remain floating 
in the air for any length of time, but sink to the floor where they are 
soon rendered innocuous, as was already mentioned. 

It is thus obvious that only when contact with the consumptive 
is very close, intimate, and prolonged, which in ordinary life occurs, 
as a rule, only in mothers with suckling infants, or between husband 
and wife, droplet infection may become a serious menace. And even 
in these cases there are natural safeguards. 

Considering the evidence thus far brought together at its face value, 
it appears that inhalation of dust containing tuberculous sputum, or 
of droplets expelled by consumptives while talking, coughing, and sneez- 
ing, may infect a healthy person, yet the evidence that these are the most 
frequent modes of the dissemination of tuberculosis is inadequate. 

From time immemorial physicians have attributed the transmission 
of infectious diseases to the inhalation of the virus. To the ancients 
" infection" meant everything that contaminates the air (Infection, 
from the Latin infection em, infectus, or more exactly impregnated). 
This has notably been the case with the endemic diseases of childhood, 
and for a long time yellow fever, typhoid, typhus, malaria, relapsing 
fever, etc., were all considered inhalation diseases and proofs were at 
hand to substantiate these contentions. Recently more exact studies 
have shown conclusively in some, and with a high degree of probability 
in others, that they are altogether transmitted through the agency of 
certain insects. Indeed, physicians of a few generations ago drew 
analogies between tuberculosis and malaria, typhus, etc., showing that 
they were all caused by the inhalation of the virus. 

Natural Barriers against Inhalation Infection. — Notwithstanding 
the various disharmonies which may be found in the structure and 
functions of the human body, and which Metchnikoff has so cleverly 
enumerated in one of his books, the respiratory tract is provided with 
a most wonderful protective apparatus for the prevention of the 
entry and implantation of bacilli in the deeper respiratory passages. 
Indeed, no organ in the body, excepting the central nervous system, 
is fitted out with better safeguards in this regard. 

The bacilli cannot enter the lungs with ease, The nasal passages, 



Hi TUBERCULOUS INFECTION 

mouth and throat act as excellent filters, detaining the inhaled dust. 
EveD when some microorganisms in the inhaled air pass all the bar- 
riers, the mucus secreted all along the tract, the ciliated epithelium, 
etc., soon remove them as foreign bodies, when necessary assisted by 
cough, which has the function of clearing the lungs. The few bacilli 
which may remain within for any reason are, under normal conditions, 
well cared for by the extensive lymphatic apparatus which surrounds 
all the bronchi and bloodvessels, even the terminal bronchioles, and 
takes up bacteria, destroying them or at least rendering them innoc- 
uous. " It was one of the earliest observations that often the glands 
apparently held up, or arrested, the further progress of the infecting 
agent," says Allen K. Krause. 1 ". . . Arrested, healed or scarred 
tuberculosis in lymphatic glands was one of the commonest findings; 
so frequent and so pronounced a phenomenon, that more than one 
observer hazarded the speculation as to whether glandular tissue may 
not differ from other tissue in that inherent in the former was some sub- 
stance, some specific stuff, that was antagonistic to the development 
of the tubercle bacillus." From animal experiments, conducted for 
years, Bacmeister ? shows that while tubercle bacilli are only rarely 
found in the lungs of animals compelled to inhale dust containing the 
germs, he never observed that infection of the normal lung should be 
caused in this manner, and he concludes that the bacilli must be hin- 
dered in their development, destroyed or carried away from the lungs 
by the lymph and blood stream. There is no reason against the 
assumption that the normal human lung acts in the same manner 
and that numbers of bacilli which may succeed in penetrating into 
deep air vesicles are removed or destroyed before they can gain a 
foothold and cause disease. 

It must, however, be borne in mind that dust of any kind may and 
does reach the lungs with the inspired air, as is evident from the 
large number of cases of pneumokoniosis of various degrees. Tubercle 
bacilli may thus be brought there with the inspired air. But whether 
they cause disease in every case in which they reach the lungs is a dis- 
puted problem, the weight of evidence being against such a contention. 
Indeed it has been proved that tubercle bacilli may remain alive and 
virulent in the tracheobronchial glands for years without causing 
disease, or even changes in the glands. Investigations by Bartel and 
Weichselbaum, Harbitz and others have shown that this is frequently 
the case, and it explains the latency of tuberculosis in many cases. 

That tubercle bacilli on mucous membranes are not invariably 
causing disease is proved by another fact. These microorganisms 
have been found on the mucous membranes of the nose, throat and 
mouth of healthy individuals. Xoble W. Jones 3 found them in the 

1 Am. Review of Tuberc, 1918, ii, 718. 

2 Die Entstehung der menschlichen Lungenphthise, Berlin, 1914. 

3 Med. Record, 1900, lviii, 285. 



PORTALS OF ENTRY OF TUBERCLE BACILLI 47 

nasal cavities of healthy persons in the ordinary walks of life, espe- 
cially those who cared for consumptive patients. Strauss 1 found 
tubercle bacilli in the nasal cavities of healthy individuals living in 
houses inhabited by phthisical patients. Alexander 2 found them in 
very large numbers on the mucous membranes of patients suffering 
from ozena, but who had no symptoms or signs of tuberculosis. These 
facts, taken in connection with the fact that tuberculosis of mucous 
membranes of the pharynx, nose, and mouth 1 is exceedingly rare even 
in consumptives, show that these structures possess a certain natural 
resistance against tuberculosis. That it is not solely due to the immu- 
nity acquired by previous tuberculous infection is shown by the fact 
that, as a primary infection, tuberculosis of these parts is exceedingly 
rare, though it must be admitted that while entering the body, by 
inhalation or ingestion, the bacilli must pass them. 

A lymphatic apparatus of normal structure and function evidently 
insures against the implantation and pathogenic action of all kinds of 
bacilli in the respiratory passages. Otherwise we would all succumb 
to various diseases, including tuberculosis. It is only when the natural 
protective forces fail that tuberculous infection may be caused in this 
manner. 

On the other hand, it must be emphasized that the lungs are very 
much exposed to infection from the blood stream, and hematogenic 
infection may easily localize itself in these organs. The lungs are the 
first filter for everything that may be carried by the venous circulation. 
When the lymphatic apparatus is injured by anthracosis, which is 
very frequent in city dwellers, it is not capable of removing tubercle 
bacilli which may be brought to it with the blood stream. The 
apices are located in an especially unfavorable position, and do not move 
with the respiratory activity as well as the lower parts, and when to 
this are added an ossified costal cartilage, and a short first rib, we 
have everything favorable for the localization of bacilli in the apices. 
(See Chapter IV.) 

Difficulties in the Way of Establishing the Portals of Entry of 
Tubercle Bacilli. — The reasons why experimental investigations have 
failed to adequately solve the problems of the aerogenic etiology of 
phthisis are evident when we bear in mind that pulmonary tuberculosis, 
as met with in human beings, showing isolated foci which extend sloivly 
downward in the lungs, never occurs spontaneously in animals; nor has 
it ever been induced artificially or experimentally in animals. 

Really active initial lesions in the human lungs have only rarely been 
encountered at necropsies. Most cases examined on the autopsy 
table are advanced, and it is very difficult, or impossible, to decide 
which was the initial lesion. Even the initial lesions, found in indi- 
viduals who died from causes other than tuberculosis, and reported 

1 Bull, de l'Acad. de med., Paris, 1894, xxxii, 18. 

2 Berl. klin. Wchnschr., 1903, xl, 508. 



48 TUBERCULOUS INFECTION 

by Schmorl, 1 Birch-Hirschfeld, 2 Lubarsch, 3 Beitzke, 4 and others, have 
not cleared up definitely the problem whether the bacilli were brought 
to the site of the lesion by the inspired air or the blood stream. It 
has, however, been found that even at that stage both the bronchioles 
and the bloodvessels were affected to such an extent that either, or 
both, could be considered the portal of entry. It is difficult or impos- 
sible to decide which is the initial lesion, even in experimental tuber- 
culosis. "The fixing of the portals by the so-called oldest lesion," 
says Ravenel, 5 "is open to serious question. I have produced fatal 
pulmonary tuberculosis in monkeys by feeding, with very insignificant 
intestinal lesions. All the oldest lesions were located in the lungs and 
bronchial glands, yet the method of feeding largely precluded the 
possibility of the tubercle bacilli reaching the lung, except through the 
digestive tract." 

The fact that the regional lymphatic glands and lymph nodes are 
usually implicated at an early stage points to a hematogenic localiza- 
tion, but it may also be explained by the aerogenic hypothesis. 

It is obvious that the inhalation of the bacilli does not exclude 
hematogenic distribution and their final localization at some point 
distant from the point of entry. Ribbert, Bacmeister, Lubarsch, 
Ravenel, Theobald Smith, and others, have pointed out that micro- 
organisms brought into the bronchial tree by the inspired air may pass 
through the mucous membrane into the lung tissue without producing 
a visible lesion at the point of entry; pass along the lymphatics into 
the regional lymph nodes and from there carried by the blood stream 
into the pulmonary apices. But that this is in all probability rare, 
may be assumed when it is recalled that only few bacilli can reach 
the bronchi, and of these but few are allowed to pass through the normal 
mucous membrane of these tubes and the alveoli, and they are usually 
rendered innocuous by the protective properties and functions of the 
lymph and blood, as was just shown. 

Hematogenic Infection. — Many look at phthisis as hematogenic in 
origin: The tubercle bacilli are assumed to enter the body at any 
point, the respiratory or digestive tract, or even through the skin, 
and are carried by the blood stream until they reach a point where the 
tissues have a low power of resistance, an organ which offers a favor- 
able soil for the growth and action of these microorganisms. Con- 
sidering the enormous frequency of pulmonary phthisis, it is evident 
that in the vast majority of human beings the lungs offer a good 
breeding-point for the tubercle bacilli. The localization of the bacilli 
is thus accompl shed in the same manner as their localization in joints, 
the peritoneum, the meninges, etc. — by the blood stream. 

1 Mtinchen. med. Wchnschr., 1902, xlix, 1379. 

2 Deutsch. Arch. f. klin. Med., 1899, lxiv, 58. 

3 Virchows Arch., 1913, ccxiii. * Berl. klin. Wchnschr., 1909, xlvi, 388. 
5 Jour. Am. Med. Assn., 1916, lxvi, 613, 



INFECTION BY INGESTION 49 

The hematogenic origin of phthisis is especially urged by Baum- 
garten, Ribbert, and Aufrecht. According to Baumgarten, tubercle 
bacilli in the inspired air may infect the mucous membranes of the 
upper respiratory tract whence they are carried by the lymphatics 
to the regional glands — the submaxillary, cervical, and supraclavicular, 
which are so often enlarged in tuberculous children. Entering the 
superior vena cava they may be carried by the blood stream to the 
lungs, causing typical interstitial tubercle of these organs and finally 
extend, while growing, to the alveolar walls, or within them. Aufrecht 
holds that the primary tuberculous lesion is always in the vascular 
walls, which are affected by bacilli brought to them by the blood 
stream. Through the veins they pass into the right heart; or from 
tuberculous bronchial glands they get into the pulmonary artery or 
its branches, when the lymph channels are obliterated by inflamma- 
tory processes, into the finest bloodvessels and capillaries. Aufrecht 
has done quite some experimental work in support of his contention. 

It is thus clear that the aerogenic hypothesis of the origin of phthisis 
is explained by either a hematogenic or lymphogenic localization of the 
bacilli in the lungs. The frequency of tuberculosis of the glands, 
serous surfaces and meninges speaks in favor of such origin of lung 
disease. The recent discoveries to the effect that a bacteremia is 
very frequent in phthisis support this contention. 

Infection by Ingestion. — The most important mode of hematogenic 
infection in phthisis should be the ingestion of tubercle bacilli, although 
it by no means excludes the air passages as portals of entry, because 
germs inhaled through the mouth, nose, and throat may be swallowed 
and pass into the blood through the mucous membranes at any point 
of the gastro-intestinal tract. However, in the vast majority of cases, 
it would be with food, especially with milk from tuberculous cows, 
that the bacilli would enter the body and cause disease. 

Simple as this theory appears, there are many objections to be 
considered before accepting it. The assertions of some authors that 
tubercle bacilli are invariably killed by the gastro-intestinal juices 
has been found largely incorrect, as was pointed out by Romer. To 
be sure, the gastro-intestinal juices may, and usually do, interfere 
with their rapid proliferation, and so may any fermentation in the 
intestinal tract, while the peristaltic movements of the intestines may 
soon remove them from the body; but they are not necessarily killed. 
Moreover, while a healthy, unbroken mucous membrane of the diges- 
tive tract is impermeable to tubercle bacilli, it is clear that a perfectly 
normal mucous membrane is very rare considering the different kinds 
of food and its debris which pass through it, and the least disturbance 
in its anatomical structure or function may be sufficient to permit 
the passage of bacteria through its walls. 

Experimental investigations have shown that feeding guinea-pigs, 
rabbits, and monkeys with tuberculous sputum, or with pure cultures 



50 TUBERCULOUS IXFECTIOX 

of tubercle bacilli, is effective in infecting the animal. Moreover, it 
has been found that the bacilli may pass through the intestinal walls 
into the blood or lymphatics without leaving any trace on the walls 
of the canal. 

llavenel 1 conducted feeding experiments at the State Live Stock 
Sanitary Board of Pennsylvania and frequently observed extensive 
tuberculosis of the lungs and thoracic glands in animals which showed 
slight, or even no involvement of the intestine. He introduced into 
the stomach of a number of dogs tubercle bacilli suspended in an emul- 
sion of melted butter and warm water, using a tube in order to prevent 
possible infection through the trachea. The dogs were killed after 
three and one-half to four hours, during active digestion, as much 
chyle as possible was collected, and the mesenteric glands were re- 
moved. Guinea-pigs were inoculated with this material. Tubercle 
bacilli were demonstrated in 8 of 10 experiments. The dogs were 
kept on soft food for some days before the experiment, and were purged 
with castor oil, in order to rid the intestine of all foreign matter which 
might injure the mucous membrane. Numerous sections of the intes- 
tine were examined also, but no injury could be detected. 

Because of this possibility of the tubercle bacilli entering the blood 
or lymph stream from the digestive tract, various authors have sug- 
gested the different parts of the canal, from the mouth to the rectum, 
as portals or entry of the bacilli, which are taken up by the blood and 
carried to the lungs where they finally stay and cause phthisis. Some 
have stated that irritated gums during dentition of infants offer a 
good portal of entry for the bacilli; the frequency of enlarged cervical 
glands at that period of life was cited as a good proof of the theory. 
Others have accused the tonsils, especially the pharyngeal tonsil. 
From the regional cervical glands some authors have traced the bacilli 
to the bronchial glands and finally to the lungs, though this has been 
shown by Wood 2 and Beitzke 3 not feasible for anatomical Masons. 
However, it must be acknowledged that even if there is no anatomical 
connection favoring the migration of bacilli from the cervical glands 
to the lungs, the microorganisms may be carried to any place by the 
blood. On the other hand, it must be mentioned that the tracheo- 
bronchial glands may be infected directly from the lungs by bacilli 
which have reached them with the inspired air. 

The most conclusive proof of the tubercle bacilli entering the lungs 
ma the digestive tract has been brought forward by Calmette and his 
school, also by TVhitla, and many others. Calmette 4 denies dust con- 
taining tubercle bacilli as a strong factor in phthisiogenesis. He could 
not produce anthracosis in animals after subjecting them to prolonged 

1 Jour. Am. Med. Assn., 1916, lxvi, 613. 

2 Ann. Rep. Henry Phipps Inst., 1906, iv, 163. 

3 Virchows Archiv, 1906, clxxxiv, 1. 

4 Ann. de l'Inst. Pasteur, 1905, xix, 601; 1906, xx, 353. 



INFECTION BY INGESTION 51 

inhalation of air saturated with lamp-black. Introducing dry, or moist, 
tubercle bacilli directly into the trachea by inhalation or insufflation, 
or even by inoculation, they were never found to reach farther than 
the bifurcation of the trachea. Introducing lamp-black into the stomach 
through a tube, thus excluding inhalation, or mixing it with food, 
anthracosis was soon produced in the lungs of the animals. Similarly, 
tubercle bacilli introduced carefully into the stomach through a tube 
with a view of preventing aspiration into the trachea, invariably pro- 
duced tuberculosis. 

Sir William Whitla's 1 experiments along these lines are very in- 
structive. He injected a mixture of China ink and water into the 
large vein in the ear of a rabbit. The animal was killed an hour later, 
and its lungs were found highly charged with carbon particles. He 
fed for four days a guinea-pig with an emulsion made by rubbing up 
finely powdered China ink in olive oil and water. The lung was found 
blackened by disseminated particles of carbon in the upper, and along 
the margins of the lower, lobes within from eight to twenty-four hours 
after a single dose. Whitla thus explains the migration of the carbon 
from the gastro-intestinal tract to the lungs: The carbon particles 
effect an easy entrance through the intestinal epithelial surface ; reach- 
ing the lacteal or lymphatic paths they pass through the lymphatic 
glands of the mesentery, and finally, either inclosed in phagocytes or 
free, find their way into the thoracic duct to be poured into the venous 
circulation before being arrested in the capillaries of the lungs. Vas- 
steenburgh and Grysez's experiments have also shown that it is easy 
to render an adult guinea-pig perfectly anthracotic without subjecting 
it to repeated inhalations of carbon particles. Considerable work 
along these lines has been done in this country. Schroeder and Cotton 2 
found that no matter in what part of the body tubercle bacilli are 
inoculated, pulmonary disease may result. 

Calmette's and Whitla's experiments have been repeated by many 
other authors but their results did not confirm these investigators. 
Thus, Cobbett 3 fed animals with Indian or Chinese ink, or with soot, 
using very much larger quantities than Calmette and Whitla used, 
and not once only, but many times, and in some cases daily for one or 
more weeks. In some cases it appears that he found in the older 
animals some amount of pigmentation of the lungs. But he was careful 
to examine a large number of control animals (a precaution which 
seems to have been omitted by Calmette and the others) and he found 
just as much pigmentation in them as in those animals which had been 
fed with carbon. In young animals pigment was not seen, whether 
they had been fed with carbon or not. It was clear that some amount 
of pigmentation of lungs was to be reckoned with in the older, town- 
bred animals, and Cobbett remembered that he was accustomed to 

1 Lancet, 1908, ii, 135. 2 Report of Bureau of Animal Industry, 1906, xxiii, 31. 

3 Jour. Pathol, and Bacter., 1910, xiv, 563; The Causes of Tuberculosis, p. 146. 



52 TUBERCULOUS INFECTION 

see a considerable amount of carbonization in the lungs of adult guinea- 
pigs when he was working in Sheffield. He therefore decided to repeat 
the experiments with country-bred animals; and when this was done 
no pulmonary pigmentation was seen in any of the animals, whether 
they had been made to swallow the ink or not. The anthracosis was 
thus not necessarily due to the carbon introduced experimentally. 

From these and many other experiments we are safe in concluding 
that tuberculous infection, including phthisis, may be acquired through 
the ingestion of tubercle bacilli, and that the digestive tract permits 
the passage of the bacilli, which are carried by the blood and lymph 
streams to the various points of least resistance, of which, in the human 
being, the pulmonary apices appear to be the most vulnerable. 

It is. however, a question whether this mode of infection is the most 
common in spontaneous tuberculosis in humans. We must not over- 
look the fact which has been established experimentally, that large 
numbers of bacilli are necessary to accomplish results and the normal 
gastro-intestinal tract can easily dispose of small doses of tubercle bacilli. 

Ingestion of tubercle bacilli may result in tuberculosis of the cervical 
or mesenteric glands, depending on the point at which the baciUi enter 
the upper or lower parts of the digestive canal. From these glands the 
bacilli are taken up by the circulating blood and carried to the tracheo- 
bronchial or mesenteric glands, and to the lungs. In many cases the 
bacilli remain dormant in these glands indefinitely, causing no disease 
at all; in others, the latency lasts only for some time, when finally, 
because of some exciting cause, they flare up again, migrate with the 
blood stream and, localizing in the lung, cause phthisis, and we then 
think that we are dealing with a new infection. 

Autopsies made by Gaffky, 1 Ungermann, TVollstein and Bartlett.' 2 
Ghon, 3 Hamburger, 4 and others have shown that in children both 
glandular systems — the abdominal and the thoracic — are affected in 
nearly the same proportion. Primary infection of the intestine is very 
rare in adults, though in children it is quite common. Behring, how- 
ever, believes that all infections date back to earlv infancy when the 
bacilli are ingested, remain latent to flare up again in later years, 
causing disease of the lungs (see Chapter V). Of course, while making 
autopsies on adults who died from chronic tuberculosis it is difficult 
or impossible to find the point of primary inoculation. But in infants 
and children this may be done in most cases. Perhaps one of the best 
criteria is that in primary intestinal infection the mesenteric glands 
are implicated, while the intestinal mucous membrane may remain 
intact, and in secondary intestinal tuberculosis — the ulcerations so 
frequently found in phthisical subjects — the mesenteric glands are 
only rarely affected. Statistics of primary tuberculosis of the intestine 

1 Tuberkulosis. 1907, vi. 437. - Am. Jour. Child. Dis.. 1914. viii. 362. 

3 Der primare Lungenherd bei der Tuberkulose der Kinder. Berlin. 1912. 
i Die Tuberkulose des Kindesalter, Vienna. 1912. 



SIGNIFICANCE OF BOVINE INFECTION oS 

in children are not in accord. From the data published by Orth, 
Eden, Councilman, Mallory and Pearce, Lubarsch, Wollstein and Bart- 
lett, and many others, it appears that the percentage ranges from five 
to fifty. A large proportion of these infections are due to bovine 
bacilli, as was already shown (p. 29). 

Significance of Bovine Infection. — Xor can we decide upon the 
channels of entry of the tubercle bacilli by a study of the type of 
microorganisms found in the case. We must bear in mind that cow's 
milk contains tubercle bacilli more frequently than has been appre- 
ciated. The studies of E. C. Schroeder, 1 John F. Anderson, 2 Ravenel, 
and others, have shown this to be a fact in this country. In New York 
City Alfred F. Hess 3 found virulent tubercle bacilli in 16 per cent, of 
107 specimens of milk retailed from cans. Inoculation experiments 
were carefully done and he found that guinea-pigs were infected with 
the milk, the cream, as well as the sediment. What is more note- 
worthy is that "commercially pasteurized" milk was also found to 
harbor tubercle bacilli. All bacilli found were of the bovine type, 
with one exception, in which the human variety was discovered. 
M. Rosenau 4 compiled data concerning 551 samples of milk examined 
in which tubercle bacilli were found in 46, or 8.3 per cent., and he says 
that this may be taken as the average percentage for the entire coun- 
try. But practically all the cases of pulmonary phthisis are due to the 
human type of bacilli, and in countries where milk is hardly used as 
a food, as is the case in Japan, China, India, Egypt, etc., phthisis is 
not lacking, as has been shown by Kitasato 5 and others. Moreover, 
the Imperial Health Department of Germany has made a collective 
investigation on the subject of bovine infection as a cause of tuber- 
culosis of the lungs and found that out of 280 children, all of whom 
had been fed since infancy on milk derived from cows with tuber- 
culous udders, only 2 became sick with tuberculosis during seven 
years, and not a single case of death occurred among them. Hess 6 
followed for three years 18 children in New York City who drank 
milk in which tubercle bacilli were demonstrated and found that all 
but one remained free from tuberculous disease. Only in one had 
tuberculous adenitis developed, and bacilli of the bovine type were 
cultivated from the pus of the gland abscess. 

We have seen that the tuberculosis in children caused by bovine 
infection consists almost invariably in diseased glands, skin, bones, 
joints and intestines, and fatal phthisis is exceedingly rare. There is 
also ample evidence that the adult is practically immune to the bovine 
bacilli, even if his immunity to the human type of bacilli has not yet 

1 Bull. No. 99, Bureau of Animal Industry, 1907. 

2 Jour. Infect. Dis., 1908, v, 107. 

3 Jour. Am. Med. Assn., 1909, lii, 1011. 

4 Preventive Medicine, New York, 1913, p. 513. 

5 Sixth Intern. Congr. on Tuberculosis, 1908, vi, 1. 
e Jour. Am. Med. Assn., 1911, lvi, 1322. 



54 TUBERCULOUS INFECTION 

been established to the satisfaction of all. 1 Younger individuals, 
when infected with the bovine type of bacilli find it more or less easy 
to cope with the situation and recover, even if they finally emerge 
with disfigurement, or perhaps crippled. But if the problem of tuber- 
culosis was only that part which is produced by the bovine bacilli, 
it would not have by far the significance it has at present. In fact 
several authors, especially Riviere, 2 Cobbett (see p. 128), and others, 
are of the opinion that these mild bovine infections immunize the 
organisms against infection with the more virulent human type, as 
will be discussed later on. 

Evaluation of Experimental Data. — On the whole the experimental 
evidence, though ample in quantity, is not always in agreement with 
what would be expected a priori; nor are the results of one investi- 
gator invariably the same as those obtained by another who ostensibly 
followed the- same method. 

The difference in the results of experimental investigations are best 
explained by lack of equilibrium between the host and the parasite, 
as has been found by many bacteriologists, notably Theobald Smith, 3 
who says: "It varies with the species, race, nationality, or even 
family of the host and many other accessory conditions. It depends 
on the race of the tubercle bacilli. In experiments such conditions 
as age of culture, total period of cultivation, character of the culture 
medium, condition of aggregation of the bacilli, mode of application 
and dosage are of great importance in determining the outcome of 
the experiment. Similarly, the outcome will vary according to the 
species of animal on which we are experimenting." 

There are other reasons why we should be careful before applying 
experimental finding to clinical medicine. Among various species of 
animals the results are not always the same when an experiment 
has been performed in the same identical manner and with the same 

1 Inasmuch as this may appear to be a sweeping statement, I will cite at some detail 
Felix Klemperer's experiments: In February, 1900, he injected subcutaneously bovine 
bacilli into his arm. Ten months later he excised the induiated subcutaneous cellular 
tissue at the site of the injection. Microscopic examination showed well-organized 
granulation tissue with giant cells but no caseation. No tubercle bacilli could be dis- 
covered, showing that tuberculosis was probably absent, and the tissue changes were 
at any rate not characteristic of tuberculosis. Another physician, who had been tuber- 
culous for fourteen years, also submitted to similar injections of bovine bacilli. In 
this experiment the individual was given fourteen injections without producing any 
results. Four other tuberculous patients were injected with tuberculous lymphatic 
tissue from guinea-pigs. A total number of thirty-nine injections of bovine bacilli 
were administered to these four patients. The local effects were slight. Four times 
abscesses were produced which, however, healed sooner or later. General constitutional 
effects were not observed in any case; the patients even stated that they felt better 
and they gained in weight during the treatment. Klemperer concludes that there 
is no doubt that subcutaneous injection of bovine bacillus is, within certain limits, harm- 
less to the tuberculous individual (Ztschr. f. klin. Med., 1905, Ivi, 241). Baumgarten 
performed similar experiments on cancerous patients with the same results. 

2 British Jour. Tuberc, 1914, viii, 83. 

3 Harvey Lectures, 1905-1906, p. 273. 



CONCLUSIONS 55 

culture of bacilli. Thus, as has been pointed out by Weber, after 
inoculating subcutaneously guinea-pigs with bovine bacilli there results 
disease first of the spleen, and second of the liver, but the kidneys are 
almost never affected, while in the rabbit the kidneys are affected 
next to the lungs. The lung of the hen is practically refractory to the 
typus gallinaceous of the acid-fast bacilli. In the rabbit there is 
always an infection of the lymph glands after inoculation of bovine 
bacilli, but when human bacilli are inoculated these glands are never 
affected. Inasmuch as the internal organs are affected after subcutane- 
ous inoculation, it is evident that the bacilli pass the regional lymph 
glands without harming them. Rats respond to infection with the 
human type of bacilli in the same way as rabbits. There is no doubt 
that various strains of the same type of bacillus produce different 
results when inoculated into the same species of animals, and in 
humans the different types of disease resulting from infection may 
undoubtedly be attributed to similar causes. Chronic phthisis is a 
distinctly human disease which never occurs in animals spontaneously, 
nor has it ever been induced experimentally. 

Conclusions.— A survey of the evidence presented in this chapter 
shows clearly that there is no agreement among authorities as to the 
mostcommon channel of entry of the tubercle bacilli before causing phthisis. 
The reason is clear when we bear in mind that experimental investi- 
gations in laboratories have in most cases not duplicated natural 
conditions among human beings. Charles V. Chapin, who has so 
well pointed out this fact, arrives at the conclusion that it is highly 
desirable that a sufficient number of well-conducted experiments 
under truly natural conditions be made to determine the relative 
importance of inhalation of desiccated sputum, and the ingestion of 
the bacilli in the spread of the disease. Romer, perhaps the most 
indefatigable experimental worker in the field of tuberculosis, also 
says that there is evidently some mode of transmission of this disease 
with ivhich we are as yet unacquainted. 

It must, however, be mentioned here, a point which will be dis- 
cussed in detail later on, that infection alone is not sufficient to produce 
phthisis; the disease occurs, after all, in only a certain proportion 
of persons infected with the tubercle bacilli. In other words, while 
there is no phthisis without tubercle bacilli, these microorganisms can 
only harm one who is predisposed to the disease. Under the circum- 
stances phthisio genesis is more a problem of predisposition than of 
infection. 



CHAPTER III. 
THE EPIDEMIOLOGY OF TUBERCULOSIS. 

Ubiquity of the Tubercle Bacillus. — In our survey of the biological 
characteristics and the channels of entry of the tubercle bacilli we 
found that the virus of tuberculosis is ubiquitous ; that it is found where- 
ever civilized human beings congregate, because tuberculous human 
beings expectorate sputum containing these bacilli, and domestic 
animals affected with this disease are everywhere. It has been esti- 
mated that the number of bacilli discharged daily in the sputum of 
a single patient with advanced phthisis is as great as the number of 
human beings on the earth. The modest estimate mentioned by 
Cornet may be taken as near the truth — that 7,200,000,000 bacilli 
may be thrown off daily from a single patient. If we imagine each 
organism placed end to end in a single file, this number would con- 
stitute a chain not less than twelve miles in length. 

Clinical and experimental medicine have shown conclusively that 
the expectoration of consumptives, milk from tuberculous animals, 
etc., are capable of causing infection; that these microorganisms may 
enter the body through wounds, as well as through the unbroken 
skin, and the mucous surfaces of the respiratory and alimentary tracts, 
etc. We have also shown that though there are many hindrances 
in the way of infection, still, when everything stated in the preceding 
chapter is considered, it is not surprising that one out of eight in 
civilized countries succumbs to the disease, but that the other seven 
escape its ravages. 

Tuberculous Infection vs. Tuberculous Disease. — As a matter of 
fact very few escape infection with the tubercle bacilli, especially 
those living in large industrial cities. When we make this statement 
we want to emphasize that a distinction is to be made between tuber- 
culous infection and tuberculous disease. The latter refers to the 
disease known for centuries, ever since Hippocrates described it, 
as consumption, or the equivalent of the term found in all European 
languages. It is the disease which causes more than 95 per cent, of 
the suffering, social and economic misery and deaths due to the tubercle 
bacilli. On the other hand, tuberculous infection covers all the cases 
in which the virus of tuberculosis has entered the body, irrespective 
of whether it has caused disease or not. Tuberculous disease is always 
preceded by infection, but infection with the tubercle bacilli is not inva- 
riably followed by disease. 

Research of the past three decades has shown conclusively that 



FREQUENCY OF TUBERCULOUS INFECTION 57 

infection with tubercle bacilli is not invariably followed by that train 
of symptoms which we observe in phthisis ; that it does not necessarily 
cause any sickness, excepting an altered reactivity to tuberculin. 
Apparently more people harbor the bacilli within their bodies, or show 
traces of having harbored them, without knowing it at all, than such 
as suffer or succumb as a result of tuberculosis of the lungs or other 
organs. These persons are undoubtedly tuberculous, and there are 
many strong reasons that, like other bacillus "carriers," they are 
liable to cause mild infection with tuberculosis in others. But they 
are not at all phthisical in the clinical sense. Some of them are destined 
to become phthisical; in fact, practically all phthisis evolves from an 
infection acquired during childhood, as we shall show when discussing 
phthisiogenesis. 

Frequency of Tuberculous Infection. — Careful and painstaking 
scientific investigations have shown that the frequency of tuberculous 
infection goes hand in hand with civilization, or contact of primitive 
peoples with civilized humanity. In modern large cities very few 
persons escape infection. Autopsies made with a view of ascertaining 
traces of tuberculous lesions, both active and healed, have shown that 
over 90 per cent, of adults are thus affected among the civilized; 
but among primitive peoples who have not come in contact with civil- 
ized conditions and humanity no tuberculous changes are found at 
autopsies. 

In Laennec's 1 classical work on diseases of the lungs published in 
1831 we find the following in a footnote: "M. Lombard's investiga- 
tions in the Children's Hospital at Paris show that of the children who 
die between one and two years of age, one-eighth are tuberculous; 
between two and three, two-sevenths; between three and four, four- 
sevenths; between four and five, three-fourths. In the succeeding 
years up to puberty, tubercles are found more frequently than before 
the fourth, but much less frequently than from the fourth to the 
fifth. Papavoine, of the same hospital, found that the number of 
tuberculous children between the fourth and eleventh years is greater 
than those who are not tuberculous, tubercles being particularly 
prevalent from the fourth to the seventh years. Their frequency is 
again increased about the twelfth and thirteenth years, and at four- 
teen and fifteen years the rate of prevalence is the same as at four 
and five. These results were obtained from investigations made on 
910 children (388 boys and 522 girls) ; somewhat less than three-fifths 
were tuberculous." 

Similarly, Henry Ancell 2 emphasized the extent of tuberculous disease 
in London as far back as 1840. In a paper on "Facts and Opinions 
Relating to Tuberculosis, with Commentaries," he cites the Decenium 
Pathologicum of Dr. L. K. Chambers, giving the results of the post- 

1 Traite de l'auscultation mediate et des maladies des poumons et du coeur, Paris, 
.1831, ii, 125. 

2 Assn. Med. Jour., 1853, p. 1030; quoted from Karl Pearson, loc. cit., p. 19. 



58 THE EPIDEMIOLOGY OF TUBERCULOSIS 

mortem examinations made in the mortuary of St. George's Hospital 
in the ten years, December 31, 1840, to December 31, 1850. The 
number of autopsies was 2046. The following are the figures: 

Birth to Above 

15 years. 15 to 30. 30 to 45. 45 to 60. 60. All 

Total number of autopsies ... 154 636 651 438 167 2046 

Per cent, of tubercle found . . . 29 J 35.8 25.8 19.6 7.7 26.1 

It appears that these facts were entirely forgotten, and medical 
literature was silent about the extent of tuberculous infection and 
changes in the bodies of many who have shown no indication of disease 
during life, until in 1900 Naegeli 1 published his report of 500 autopsies 
at the Pathological Institute at Zurich. He found 71 per cent, showed 
pathological changes due to tuberculosis. Among individuals under 
eighteen years of age, only 25 per cent, showed such, lesions, mostly 
of a grave character, often leading to a fatal termination. But in 
persons above eighteen years of age the proportion that showed traces 
of tuberculous infection reached 98 per cent. Of these, only 28 per cent, 
died as a result of this disease, while the rest had tuberculous foci 
which were either altogether healed, or quiescent, or slowly progressing. 

When first published this revelation appeared incredible, but then 
other pathologists investigated autopsy material along the same lines, 
and they practically confirmed Naegeli 's findings. From the works 
of Harbitz, Scheel, Burckhardt, Lubarsch, Adami and McCrae, 2 and 
many others, it was clear that very few persons escape infection with 
tubercle bacilli before reaching the age of maturity. They have all 
found that no matter what the cause of death may have been, whether 
the persons knew that they had been tuberculous or not, between 50 and 
100 per cent, of people living in large cities show active, quiescent or 
healed tuberculous lesions in some organs of their bodies. On this point 
all are now in agreement, the only dispute which may be found in the 
literature consists in whether the percentage is only 70, or reaches as 
high as 100. Thus, Lubarsch 3 states that Naegeli has exaggerated 
his findings, because of 7371 necropsies performed by Naegeli, Burck- 
hardt, Risel and Lubarsch, only 4230, or 57.4 per cent., showed tuber- 
culous changes; of 5796 necropsies on adults, 4017, or 69.2 per cent., 
showed such changes. 

These autopsies showed another significant fact: The newborn 
infant is invariably free from tuberculosis, indicating that infection, 
if it occurs at all, always takes place after birth. Among infants dying 
during the first year of life from any cause, some are found presenting 
lesions of a tuberculous character, while beginning with the second 
year the number of infected children increases steadily, so that at the 
age of fifteen there are nearly as many tuberculous among them as- 
among adults. In this country Martha Wollstein and F. H. Bartlett 4 

1 Virchows Arch., 1900, clx, 426. 

2 Tr. Sixth Internat. Congr. on Tuberculosis, 1908, i, 325. 

3 Virchows Arch., 1913, ccxiii, 417. 4 Am. Jour. Dis. Children, 1914, viii, 364. 



FREQUENCY OF TUBERCULOUS INFECTION 59 

reported 1320 autopsies performed at the Babies' Hospital in New York 
City on children under five years of age, of which 118, or 13.5 per cent., 
showed tuberculous changes. In Europe the proportion is even higher, 
as is evident from the finding of Xaegeli, Burckhardt, Lubarsch, 
Hamburger, and many others. 

In England autopsy material has shown the same conditions. 
Eastwood and F. Griffith, in London, and A. S. Griffith, in Cambridge, 1 
have examined the organs and glands of 215 children who died from 
various causes in general hospitals, inoculating animals, etc. The pro- 
portion harboring tubercle bacilli is shown in the following table: 

Number infected with Proportion 

Age. tubercle bacilli. infected. 

to 2 years 6 out of 17 35 per cent. 

2to 4 " 18 " 82 52 

4 to 6 " 36 " 62 58 

6 to 10 " ....... 39 " 51 77 

10 to 12 " ....... 2 " 3 

Even conceding that among children who succumb the number of 
tuberculous is likely to be higher than among those who survive, the 
proportion is still very high, — sixty per cent, of all children are shown 
to have been infected with tubercle. 

Another series of autopsies on children have been reported by Har- 
bitz. 2 In the Anatomical Institute at Christiania, Sweden, during 
1898 to 1911, the bodies of 484 children who died from any cause 
were dissected. The ages ranged from birth to fifteen years. His 
results are given in the following figures: 

Number Tuberculous lesions. 
Age. examined. Per cent. 

Oto 1 year 201 20.0 

1 to 2 years 65 26.2 

3 to 4 " 44 31.8 

5 to 6 " 28 67.9 

7 to 10 " • 53 62.2 

11 to 14 " 53 81.1 

15 " 40 80.0 

Total 484 41.08 

The anatomical picture was predominantly that of tuberculosis of 
the lungs and the lymphatic glands, especially those of the thorax. 
The younger the child, the more acute and progressive the lesion 
found. In only one case could he suspect congenital tuberculosis. 

The most recent series of autopsies reported are those collected by 
A. Reinhart. 3 For eighteen months he made a special study of all cases 
that came to autopsy at the Berne Pathological Institute, looking for 
evidences as to the frequency of tuberculous lesions. In all he per- 
formed 460 autopsies. Among the 28 newborn infants no traces of 
tuberculosis were found; in 72 children under sixteen years of age, 

1 Report to the Local Government Board on Public Health, N. S., No. 88. 

2 Norsk mag. f. Laege videsk. , 1913, 5 R., xi, 1. 

3 Cor.-Bl., f. schweiz. Aerzte, 1917, xlvii, 1153. 



60 The epidemiology Of tub^rcvlosi^ 

29.16 per cent, showed active tuberculous lesions, although only 16.8 
per cent, had succumbed to this disease. He again confirmed the results 
of nearly all other pathologists to the effect that the number of tuber- 
culous lesions increases with the advance of the age of the children. 
The infants under one year suffered the least, only 7.14 per cent. 
Among 360 cadavers of adults, 96.38 per cent, were found with tuber- 
culous lesions; negative results were encountered in only 13 cadavers, 
and of these 9 were under thirty years of age. Here again there is 
evidence that most tuberculous lesions heal: In 63.9 per cent, of the 
adults the lesions were found healed; the older the individuals, the 
higher the proportion of healed lesions. It is also noteworthy that the 
difference between the incidence of healed lesions in town dwellers 
(92.9 per cent.) and country dwellers (98.1 per cent.) is rather slight. 

Another point has been brought out by these autopsies which 
is of immense epidemiological and clinical importance. The tuber- 
culous lesions found at the autopsies are not all active, nor were 
they the cause of death in many cases. Indeed, there were many which 
were latent, quiescent, or even healed. Thus among the 406 tuber- 
culous bodies examined by Naegeli, 28.1 per cent, had healed or 
latent lesions; among Burckhardt's 1452 autopsies he found 1221, 
or 84.1 per cent., tuberculous; but 39.4 per cent, of them show T ed 
quiescent, latent or healed lesions, and Reinhart found 70 per cent, 
inactive lesions. The results of nearly all other investigations show 
the same conditions. 

Active and progressive lesions, leading to death, are characteristic 
of infancy; in fact, during the first year of life all lesions discovered 
at autopsies are those of generalized and progressive tuberculosis. 
Localized lesions are rare in childhood, and only make their appearance 
after the second year, but are still rare at ten years of age. Available 
pathological evidence tends to show that the younger the individual 
infected with tuberculosis, the more likely he is to be killed by the disease, 
while the older the individual, the less is he likely to suffer from acute and 
progressive disease. In fact, Lubarsch says that among older persons 
tuberculosis is a relatively harmless process, showing, as it does, a 
strong tendency to latency or healing. He illustrates this point by the 
following statistical facts: 

Among 502 infants under one year examined after death, 4.58 per 
cent, were found with tuberculous lesions all of which were acute or 
subacute general tuberculosis, without any tendency to localization 
in a single organ. Of 123 children two years of age, 20.3 per cent, 
were found with tuberculous lesions. All were also active and pro- 
gressive, though there were already seen tendencies to localization 
of the process, but no calcification was noted. At three years of age 
24.7 per cent, of the bodies showed tuberculous changes, and in one 
some evidences of calcification w r ere found microscopically in a tuber- 
culous bronchial gland. He found that the number of active and 
fatal cases of tuberculosis keeps up at a high level till the age of fifteen, 
when localized tuberculosis begins to manifest itself, though the 



FREQUENCY OF TUBERCULOUS INFECTION 



61 



lesions still show tendencies to progression, and calcification is still 
exceptional. Thus, among 139 tuberculous bodies of individuals 
between one and sixteen years of age, only 33, or 23.7 percent., showed 
calcified foci, but none was completely healed — all were active and 
progressive in character. 

Only after the seventeenth year of life are to be noted latent and 
healed tuberculous lesions at autopsies, and they keep on increasing 
in frequency, so that at the age of forty they are more frequent than 
progressive lesions. The following table, as well as Fig. 1, shows the 
point clearly: 



Age. 



Active lesions. 
Per cent. 



17 to 20 


-77.4 


20 to 30 


76.7 


30 to 40 


52.6 


40 to 50 


38.9 


50 to 60 


33.5 


60 to 70 


23.3 


70 to 80 


14.7 


80 to 90 


9.3 


90 to 100 


...... 0.0 



Latent and 

healed lesions. 

Per cent. 

22.6 
23.3 
47.4 
61.1 
66.5 
76.7 
85.3 
90.7 
100.0 



These data must be considered underestimates, rather than over- 
estimates, because while dissecting lungs and pleura? slight and healed 
lesions may be overlooked, unless serial sections are made. Eugene L. 
Opie, 1 of St. Louis, attempted to overcome this possible source of error 
by an ingenious method. While making autopsies on 93 children 
under eighteen years of age, and 50 adults, he radiographed each lung, 
and since calcium salts are impervious to the .r-rays, small nodules 
which could not be detected on inspection and dissection were easily 
discovered. He thus found that partially calcined foci containing 
caseous material of soft, friable consistence are conspicuous in a>ray 
plates. In some specimens tuberculous nodules seen on the plate 
could not easily be found on dissection, but careful search always re- 
vealed them. In all doubtful cases concerning the nature of a lesion, 
microscopic examination of the tissue was made. It is thus clear that 
Opie's work was very carefully done. 

His results are given in the following table: 







Tuberculosis. 






Age (years). 


Number of 
autopsies. 


Present. 


Fatal. 


Non-fatal 


have died 
with other 














Number. 


Per cent. 








Under 1 . . . 


43 


4 


9.3 


4 





0.0 


1 to 2 






16 


1 


6.2 


1 





0.0 


2 to 5 






14 


6 


42.8 


3 


3 


27.3 


5 to 10 






11 


5 


45.5 


2 


3 


33.3 


10 to 18 






9 


6 


66.7 


1 


5 


62.5 


18 to 30 






6 


6 


100.0 


1 


5 


100.0 


30 to 50 






23 


23 


100.0 


1 


22 


100.0 


50 to 70 






15 


15 


100.0 


1 


14 


100.0 


70 and over 






6 


6 


100.0 





6 


100.0 



Jour, Exper. Med., 1917, xxv, 885; xxvi, 263. 



62 



THE EPIDEMIOLOGY OF TUBERCULOSIS 



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RELIABILITY OF AUTOPSY STATISTICS 63 

Here again it is clear that in this country the number of persons 
infected with tuberculosis is not less than has been observed in Europe, 
though most of the lesions have not been the cause of death, but have 
healed, leaving but scars or calcified nodules. "The age of incidence 
of focal tuberculous lesions of the lungs," says Opie, "demonstrates 
that they have their origin in most instances in childhood. Focal 
lesions which heal have been found at all ages after the second year of 
life, but in more than half of all individuals these lesions are acquired 
between the ages of ten and eighteen years. In the period between 
eighteen and thirty at least 85 per cent, of all individuals have acquired 
focal tuberculous lesions. The occurrence of tuberculous infection in 
the lungs, in the regional lymphatic nodes, or in some other organs of 
the body, such as the gastro-intestinal tract and its lymphatic system, 
is nearly universal, but doubtless a few individuals escape. That focal 
tuberculous lesions of the lung are occasionally acquired during adult 
life is shown by the slight increase in the proportion of those with 
these lesions as age increases from eighteen years to old age." 

The frightful tuberculization "of humanity, as revealed by these 
autopsy findings, was explained by some authors as due to the fact 
that in hospitals there is a concentration of tuberculous sick, and among 
children who succumb at an early age, the percentage of tuberculous 
should be much higher than among those who survive till maturity. 
But it must be recalled that these autopsy findings were obtained in 
children who died from all causes, and that in many the tuberculous 
lesions were found incidentally, although the causes of death were 
entirely different diseases. 

Reliability of Autopsy Statistics. — Many objections have been raised 
against these autopsy statistics showing that nearly every adult living 
in a modern city harbors tubercle bacilli within the body. Some 
have maintained that many non-tuberculous changes in the lungs 
and pleura have been included as "latent" or "healed" tuberculosis. 
But Naegeli, Burkhardt, Reinhart, Opie, Griffith, and most others, 
state distinctly that extreme care had been taken before pronouncing 
doubtful pathological changes as tuberculous. Some, like Opie and 
Reinhart, have made microscopical studies of the tissues before decid- 
ing; Griffith inoculated guinea-pigs, etc., before deciding. - 

It has also been suggested, especially by Cornet, that these latent 
lesions were caused by avirulent, or mildly virulent tubercle bacilli, 
perhaps even by some of the non-pathogenic acid-fast microorganisms 
which abound in nature. But this has been disproved for the first 
time by Loomis who injected such glands into rabbits and found 
that they were infected with tuberculosis. Cobbett, 1 when working 
for the Royal Commission on Tuberculosis in England, found that 
definitely caseous nodules taken from the lymphatic glands of children 
might be quite incapable of setting up tuberculosis when emulsified 

1 The Causes of Tuberculosis, p. 70. 



64 THE EPIDEMIOLOGY OF TUBERCULOSIS 

and injected into animals, even when the injections were made in such 
a susceptible animal as the guinea-pig. This was surprising, but what 
was more surprising still, the caseous matter thus shown to be totally 
devoid of infective power might contain plenty of well-formed tubercle 
bacilli, easily visible under the microscope. Similar experiences were 
recorded by A. S. Griffith, Weber, and others. This would tend to con- 
firm Cornet's view that the lesions were produced by avirulent, or 
mildly virulent, tubercle bacilli, and for this reason the disease they 
produced was not active nor fatal. But other investigators did find 
virulent tubercle bacilli. Thus, Lydia Rabinowitsch 1 found that com- 
pletely calcified glands, in which no tubercle bacilli could be found 
microscopically, were still capable of infecting animals. Eastwood and 
Griffith even cultivated tubercle bacilli from glands of 72 children, 
34 of whom were apparently non-tuberculous. 

It is thus clear that the tubercle bacilli found in the healed lesions 
of persons who have succumbed to diseases other than tuberculosis are 
often alive and virulent. 

The objection has also been raised that the autopsy material 
obtained in morgues in large cities represents the lowest grades of 
society, the poorest strata of population, who are most likely to suc- 
cumb to tuberculosis, while the well-to-do or self-supporting elements 
of society, even in cities, are by no means tuberculous to such an 
appalling extent. But it is the poor who present the problem of tuber- 
culosis most acutely. Xaegeli also pointed out that his material was 
not exclusively of the lowest strata of society. Forty per cent, at 
least were country folk, and 6.5 per cent, were private patients. 
Moreover, only in 22.5 per cent, was tuberculosis the cause of death, 
as against 28 per cent, occurring among the general population of the 
Canton of Zurich, thus showing that the persons on whom he made 
his autopsies were not excessively tuberculized. 

Better confirmation of these findings was, however, supplied by 
several series of autopsies made on persons who have enjoyed good 
health but succumbed to accidents or acute diseases. Among 826 
autopsies made on such individuals, Birch-Hirschfeld 2 found 171, or 
20.7 per cent., with tuberculous lesions. Of these, 105, or 12.7 per cent., 
were healed lesions; 31, or 3.8 per cent., were actively advanced; 35, 
or 4.2 per cent., were latent or mildly active. Similar results were 
recently reported by J. G. Monckenberg, 3 who made autopsies on 
85 soldiers fallen in the "World War. In 25, or 31.76 per cent., he 
found distinct evidences of active, latent, or healed tuberculosis. In 
5 cases the lesions were so active that they may have been the cause 
of death, but in the remaining 22 cases the tuberculous lesions were 
incidental findings. 

Extent of Tuberculous Infection among the Living. — The extent of 
tuberculous infection among the living population has been ascertained 

1 Berl. klin. "Wchnsehr., 1907, p. 35. 2 Deutsch. Arch. f. klin. Med., 1899, lxiv, 58. 
3 Ztschr. f. Tuberk., 1915, xxiv, 33. 



TUBERCULOUS INFECTION AMONG THE LIVING 



65 



by the application of the tuberculin test which is even more delicate 
than the macroscopic examination of the body after death, showing, 
as it does, the number of persons infected with tubercle bacilli and 
who have survived or have not at all suffered as a result of the 
infection. No matter how slight the lesion produced by the tubercle 
bacilli, the tuberculin test reveals it. 

Extensive investigations have been made along these lines, and it 
was found that there are very few adults living in cities who do not 
react to tuberculin. Those who live in tubercle-laden surroundings 
hardly ever escape infection. Pollak 1 found that in Vienna 96 per 
cent, of children of tuberculous parentage were infected before they 



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AGE 6mos. 6-12mos. 2yrs. 



YEARS 



Fig. 2. — Proportion of children reacting to the cutaneous tuberculin test. Black 
line represents 692 children of tuberculous parentage in New York City; dotted line 
represents 588 children of non-tuberculous parentage in New York City. 

reached the fourth year of life; Mantoux 2 found that 84 per cent, 
were infected before they reached the fifteenth year; in New York 
City the author 3 has found that children living with their tuberculous 
parents are infected to the extent of 84 per cent, at the age of fourteen, 
as can be seen from the table and the attached diagram (Fig. 2). 
Similar results have been obtained while testing large numbers of 
children of tuberculous parentage in various European cities. 

Taking apparently healthy children at random, i. e., those who 
do not live in homes harboring evidently tuberculous persons, it 



1 Brauer's Beitr., 1911, xix, 469. 

2 Semaine med., 1909, xxix, 371; Presse med., 1910, xviii, 10. 

3 Arch. Pediat., 1914, xxxi, 96, 197. 



66 THE EPIDEMIOLOGY OF TUBERCULOSIS 

appears that they are also infected in large numbers. Hamburger 1 
found that at the age of fourteen 94 per cent, of the children of artisans 
in Vienna show signs of infection with tuberculosis. Calmette 2 at 
Lille, France, testing 1226 persons of all ages taken at random from 
diverse social strata, all apparently healthy, found that during the 
first year of life only 9 per cent, were infected, but the percentage 
kept on increasing, so that at the age of fifteen and over, 87 per cent, 
were infected. In New York City the author 3 found while testing 
children of poor, but non-tuberculous parentage, that under one year 
of age 10 per cent, were infected; between one and two years of age, 
33.33 per cent., and the proportion giving positive reactions to tuber- 
culin kept on growing steadily with advancing age so that at the age 
of fourteen, 75 per cent, of "reactors" were found. 

Table Showing Extent of Tuberculous Infection among the Poorer Classes 

in New York City Based on the Application of the Tuberculin 

Test on 1280 Children under Fifteen Years of Age. 

Percentage giving positive reactions among 







Children of tuberculous 


Children of non-tuberculous 






parents. 


parents. 






Number of 


Number of 


Age 




cases. Per cent. 


cases. Per cent. 


Under 1 


year 


. . . 33 15.15 


56 10.07 


1 to 2 


years . 


. . . 49 55.10 


39 33.33 


3 to 4 


u 


. . . 90 68.88 


80 41.25 


5 to 6 


" 


. . . 95 65.26 


106 50.00 


7 to 10 


" 


. . . 244 71.31 


173 64.74 


11 to 14 


" 


. . . 181 74.58 


134 69.40 


14 


" 


. . . 37 83.79 


20 75.00 



It is well known that the von Pirquet test, which was used in these 
cases, is occasionally negative when applied the first time, but is 
positive when applied a second or third time. For this reason some 
who have applied the test but once found a lesser number of reactors. 
J. B. Manning and H. J. Knott, 4 in Seattle, tested 228 children, aged 
ten to fourteen years, coming to the Children's Tuberculosis Clinic, 
the large majority of which were from tuberculous homes. Of 166 
with a definite history of exposure 84, or 50.6 per cent., gave a positive 
von Pirquet test, though 82.1 per cent, of these children showed no 
clinical evidences of tuberculosis. Of 62 children with no history of 
exposure 14, or 22.8 per cent., were reactors. But they used only one- 
half strength of tuberculin, and when found negative after the first 
application, the test was not repeated. Had they applied it twice or 
three times, and in full strength, the proportion of reactors would 
undoubtedly have been higher. George H. Cattermole 5 tested children 
in Boulder, Colorado, where there is no overcrowding, but plenty of 
good food and sunshine. Probably one-half the families in Colorado 

1 Die Tuberkulose im Kindesalter, Berlin, 1913. 

2 Calmette, Grysez et Letulle, Presse med., 1911, xix, 651. 

3 Arch. Pediat., 1915, xxxii, 20. 

4 Am. Jour. Dis. of Children, 1915, x, 354. 

5 Jour. Am. Med. Assn., 1915, lxv, 782. 



TUBERCULOSIS AMONG PRIMITIVE PEOPLES AND RACES 67 

contain one or more adult consumptives. It would be expected that 
the -number of reactors should be quite large. Yet only 38 per cent, 
were found to have been infected. This anomaly may be explained 
by the superior social and economic conditions, but it seems to me 
that the following reasons are more plausible : The number of children 
was rather small, only 66; if he had extended his investigations the 
results might have been different; he applied the test but once in 
most cases, using the von Pirquet and the Moro tests. At any rate 
it appears that opportunities for infection were not altogether counter- 
balanced by superior climatic and economic conditions. 

While it is in large industrial cities that tuberculosis is most wide- 
spread, as is shown by the high morbidity and mortality from the 
disease, infection is not lacking in rural communities of civilized 
countries. Investigations made by Jacob, 1 Hillenberg, 2 Overland, 3 
and others have shown that in villages, where a case of open tuber- 
culosis had not been seen for many years, the people living under 
good economic and hygienic surroundings, and where the milk supply 
was practically free from tuberculous contamination, 25 per cent, of 
the school children and about 45 per cent, of the adults gave positive 
reactions to tuberculin, indicating that they had not escaped tuber- 
culous infection. Here we find that the effect of infection is only an 
altered reactivity to tuberculin, and not phthisis. The reasons for 
this phenomenon will be discussed later on. 

Tuberculosis among Primitive Peoples and Races. — The only 
regions free from tuberculosis appear to be those inhabited by primitive 
peoples who have not come in contact with civilization. Thus, the Ameri- 
can Indian, before the advent of the white man on this continent, 
knew nothing of the disease, as was shown by Woods Hutchinson, 4 
Hrdlicka, 5 and others. Nor do the savage and barbarian races of 
Central Africa and Asia seem to have had experience with tuberculosis, 
until the whites brought it to them. Among these primitive peoples 
the tuberculin reaction is always negative, and autopsies made on 
their dead reveal no active or healed tuberculous lesions, as is the 
case with newborn infants among Europeans. But it appears that as 
soon as these peoples come into contact with civilized man they are 
infected in large numbers. This was observed among the American 
Indians, the native tribes of Australasia and Africa, etc. The application 
of the tuberculin test among these races by Calmette, 6 Metchnikoff, 7 
Zieman, 8 and others has shown clearly that the frequency of tuber- 
culous infection depends directly on their contact with civilization. 

1 Die Tuberkulose und die hygienische Misstande auf dem Lande, Berlin, 1911. 

2 Tuberkulosis, 1911, x, 254. 

3 Internat. Zentralbl. f. Tuberkulose, 1914, viii, 635. 

4 New York Med. Jour., 1907, lxxxvi, 624. 

5 Tuberculosis among Certain Indian Tribes of the United States, Washington, 1909. 

6 Ann. de l'lnstit. Pasteur, 1912, xxvi, 497. 

7 Ibid., 1911, xxv, 785. 

8 Centralbl. f. Bakteriol., 1913, lxx, 118. 



68 THE EPIDEMIOLOGY OF TUBERCULOSIS 

It is altogether absent or extremely rare among those races who have 
recently met the white man, but the proportion grows in direct ratio 
to the intensity of immigration of European settlers, and with com- 
mercial interchange between them and civilized humanity. It is also 
evident that their immunity from this disease before the advent of 
the white man was not due to racial or climatic conditions, as was" 
suggested by some earlier writers, but solely to the absence of tubercle 
bacilli, because as soon as these are imported, the natives display a 
striking vulnerability to the disease, which is greater the longer they 
have been protected against the importation of tubercle bacilli. 

Racial Differences in Susceptibility to Tuberculous Infection. — 
A study of the epidemiology of tuberculosis also teaches that the 
dangers of tuberculous infection depend on the length of time a people 
have been exposed to the disease. Thus, when primitive peoples 
who have never been affected with this disease come into tubercle- 
laden surroundings, they are soon infected and the disease runs an 
acute and fatal course in nearly all cases. This is often the case with 
savages and barbarians brought to Europe or America: They almost 
invariably acquire tuberculosis and succumb in a short time. The 
American Indians, coming in contact with the whites and incidentally 
with the tubercle bacillus, are being decimated by the disease which 
runs an acute and fatal course among them, and the same is true of 
the negro population in this country. 

A drastic illustration has been reported by Cummins 1 from Egypt, 
where the Sudanese soldier, recruited from tribes among which tuber- 
culosis is practically unknown, is much more liable to tuberculosis 
than the Egyptian soldier who has been raised in a region where 
the disease has been quite common for centuries. In former times 
slaves of the Sudanese race were the cheapest in the market, because 
it was assumed that a large number would contract the disease and 
die. 

This is exemplified again by the conditions observed among the 
immigrants to the United States. The Irish and Sicilian immigrants, 
and to a lesser extent the Hungarians, Slavonians, and Scandinavians, 
mostly hail from agricultural parts of their native country where they 
have known very little of tuberculosis. In this country, working in 
closed factories, and coming in contact with tuberculous fellow-work- 
men, many soon contract the disease, which runs an acute course, 
terminating fatally in a large proportion of cases. Among immigrants 
coming from countries or cities where they have been exposed to 
infection for generations, as is the case with the English, Germans, 
and especially the Jews, the rates of tuberculous mortality are much 
lower. 

When speaking of race influence on the incidence and mortality 
from tuberculosis, the facts just mentioned must always be borne in 

1 Tr. Soc. Trop. Med. and Hyg., 1911-1912, v, 245. 



GEOGRAPHICAL DISTRIBUTION 



69 



mind. Tuberculosis appears not to be a racial problem — there are 
no races which are more or less vulnerable to the disease, because of 
their ethnic peculiarities, such as height of the body, color of the skin, 
eyes and hair, or other somatic or morphological traits which distin- 
guish one race from another. One human race, or ethnic group, when 
first meeting with tubercle bacilli, is as vulnerable as another. It is 
only after they have been exposed for many generations to the disease 
that they acquire a certain power of resistance against infection, which, 
though occurring in almost everyone who has been exposed to infection, 
is less liable to cause disease than in races which present virgin soil 
to the bacilli. The mechanics of this acquired immunity will be dis- 
cussed later on. 

Mortality from Pulmonary Tuberculosis per 100,000 Population. 





1861 


1866 


1871 


1876 


1881 


1886 


1891 


1896 


1901 


1906 




to 


to 


to 


to 


to 


to 


to 


to 


to 


to 


Country. 


1865. 


1870. 


1875. 


1880. 


1885. 


1890. 


1895. 


1900. 


1905. 


1910. 


United States 


















171 


147 


England and Wales 


! 253 


245 


222 


204 


183 


164 


146 


132 


122 


111 


Scotland . 


. 252 


262 


248 


229 


211 


189 


174 


165 


145 




Ireland 




183 


191 


200 


208 


212 


214 


213 


215 


191 


Australia . 










122 


121 


107 


94 


89 


75 


New Zealand 










91 


84 


81 


78 


70 


62 


*Ontario Province 










125 


116 


114 


141 


129 


113 


Germany . 








361 


348 


314 


224 


194 


186 


159f 


Prussia 








317 


312 


290 


247 


208 


191 


162 


Bavaria 














287 


262 


243 


214f 


Saxony 






251 


251 


244 


236 


212 


194 


154 


135f 


Baden 










312 


297 


278 


244 


217 


183 


*Austria . 








377 


393 


383 


394 


345 


340 


305 


Switzerland . 








200 


209 


213 


199 


190 


189 


176f 


Netherlands . 














189 


165 


133 


125 


*Belgium . 


'. 305 


305 


335 


323 


301 




165 


142 


118 


102f 


France 














255 


249 


265 


277f 


Italy .... 












137 


100 


106 


116 


123t 


Spain .... 


















148 


135 


Denmark . 








262 


249 


231 


200 


160 


149 


134f 


Norway 






108 


126 


140 


144 


173 


206 


196 


200t 


Finland 




374 


414 


367 


255 


256 


261 


273 


291 




Serbia 














251 


231 


280 


297f 


*Hungary 
















364 


397 


374 


Chile .... 












235 


269 








Japan .... 












101 


136 


145 


146 


154f 


Notes. — All figur 


es refer 


to pulmonary 


tuberculosis, except those marked * which include all 


forms of tuberculosis 























Figures in the last column marked t are only for 1906-1908. 



Geographical Distribution. — Fifty years ago Hirsch, in his classical 
study of Geographical and Historical Medicine, arrived at the con- 
clusion that tuberculosis is a disease of all times and all countries. 
With our present knowledge we have not discovered any proofs to 
the contrary. Observations in every part of the habitable globe show 
that the presence or absence of the disease is determined less by 
geographical location, or climatic phenomena, than by social and 
economic conditions and, above all, by the presence or absence of the 
tubercle bacillus. We have shown in the preceding pages that its 
absence in certain countries has not been due to either an immunity 
of the population, nor to the climate in which they live, nor to the 
altitude on which they have been located. Indeed, it is obvious that 
as soon as the tubercle bacilli are introduced among any people in 



70 



THE EPIDEMIOLOGY OF TUBERCULOSIS 



any geographical location, the disease is not slow in making its appear- 
ance. The comparative absence of tuberculosis in the Rockies, the 
Andes, and other mountainous regions, in former times was apparently 
due to the scarcity of population, and the peculiarity of the occupations 
there pursued. In the mountainous regions of the United States 
tuberculosis was scarce before consumptives began to immigrate in 
search of health. Brown, investigating conditions in El Paso, Texas, 
found that the testimony of physicians is to the effect that deaths due 
to this disease are rare among the indigenous population; E. A. 
Sweet 1 finds this to be true of the entire southwest region of this 
country, and Cattermole confirmed it in Colorado. But it appears 
that the infection of people living under good sanitary, and above all, 
economic conditions does not always produce phthisis, especially in 
regions where outdoor life is the vogue. 

Death-rates from Pulmonary Tuberculosis per 100,000 Population 
ix Various Cities. 

1881 1886 1891 1896 1901 1906 

to to to to to to 

City. 1885. 1890. 1895. 1900. 1905. 1910. 

New York 398 350 286 242 215 197 

Chicago 180 177 176 154 152 162 

BostOD . 411 377 289 240 217 175 

Philadelphia 311 269 233 210 215 206 

London 222 197 185 175 157 132 

Edinburgh 212 191 180 187 157 114 

Glasgow 311 250 227 195 170 140 

Dublin 346 341 335 317 309 268 

Belfast 382 402 382 329 307 235 

Paris 441 440 409 379 390 374 

Berlin . . . . . . . . 188 

Hamburg . . 238 200 169 137 

Munich 389 348 312 303 269 226 

Dresden 376 334 283 247 224 180 

Breslau 331 313 342 321 318 271 

Amsterdam 238 234 204 185 144 138 

Rotterdam 219 192 188 170 133 127 

The Hague 199 179 163 160 128 124 

Vienna 685 576 474 381 336 274 

Prague 728 609 512 472 525 385* 

Budapest 715 591 434 376 367 340 

Trieste 522 491 439 402 396 369 

Christiania 320 287 282 274 229 183* 

Stockholm 344 303 269 246 227 230 

Copenhagen 273 246 198 180 144 136 

Petrograd 547 449 384 321 305 301 

Moscow 411 393 391 324 268 258 

Milan 335 307 284 204 232 -220 

Turin 240 222 250 234 225 183 

Sydney 193 157 119 98 98 72 

Melbourne 233 213 182 153 139 109 

Montreal 282 256 235 250 197 163* 

Toronto 203 207 242 234 174 

Rio de Janeiro .... 548 . . 446 474 455 402 

Figures marked * indicate that the death-rate in the last column is only for 1910. 



Public Health Reports, 1915, xxx, 1059, 1147, 1225. 



INCIDENCE AMONG RURAL AND URBAN RESIDENTS 71 

Incidence among Rural and Urban Residents. — Of greater influence 
than climate and altitude appears to be life in the city, when com- 
pared with life in the country, as regards the morbidity and mortality 
from tuberculosis. It appears that country dwellers, while not exempt 
from infection with tubercle bacilli, are less likely to suffer from 
phthisis than city residents. Thus, the average death-rate from 
tuberculosis of the lungs in the registration area of the United States 
during the decade ending with 1909 was 154.7 per 100,000 population, 
but in the cities of the registration area the rate was 177.4 against 
a rural death-rate of but 124.1 . These differences would be even greater 
if we excluded the rural centers in which factories, mills, mines, etc., 
are located and where the workers live to all intents and purposes 
under the same conditions as those in the cities. These differences in 
the mortality from phthisis are found in every country where vital statis- 
tics are gathered. In England and Wales the mortality per million 
population was in 1913: London, 1335; England and Wales, 1004; 
rural districts, 742; all urban districts, 1075. The table on page 70 
shows the high mortality-rates from this disease in large cities in various 
parts of the world. When compared with the rates for the entire 
country, as given on page 69, the differences are clear. 

The establishment of sanatoriums for consumptives in rural districts 
during recent years has apparently increased the mortality from this 
disease in certain country districts. Thus, in 1910 the death-rates from 
pulmonary tuberculosis in the State of New York were : in cities, 165.7 ; 
and in the rural districts, 120.1, while in Colorado, the Mecca of 
American consumptives, the rates were : cities, 288.2; in rural districts, 
155.9. It is thus evident that with superior climate and altitude, 
Colorado has a higher mortality from pulmonary tuberculosis than 
the State of New York. Of course, the reason is that most of the fatal 
phthisis in Colorado is imported. 

Wherever available, statistics show clearly that there is more fatal 
tuberculosis in cities than in the country. The reasons for this dis- 
parity are to be sought not only in the outdoor life which country 
dwellers indulge in more than city people, but more in the difference 
in social and economic conditions. 

The higher mortality from phthisis in towns as compared with 
rural districts appears to affect only the male population, as has 
recently been shown by Benjamin Moore. 1 In the country districts 
of England and Wales it appears that the mortality of females is 
higher than that in the cities. In both town and country nearly 
twice as many girls as boys die from phthisis between the ages 
of ten and fifteen. While until the twentieth year the mortality 
from pulmonary tuberculosis of both sexes is greater in rural dis- 
tricts than in urban districts, between the twentieth and thirtieth 
years the condition in the towns become reversed. After the thirtieth 

1 Lancet. 1918, ii, 618. 



72 THE EPIDEMIOLOGY OF TUBERCULOSIS 

year the disease preponderates greatly among urban males as com- 
pared with urban females. Moreover, the disparity of the phthisis 
mortality just mentioned is a recent phenomenon; it was not observed 
in the returns of seventy years ago. It is apparently due to the recent 
changes in the social and economic conditions of the population 
brought about by the recent industrial conditions of the working 
classes. 

Social and Economic Factors. — There is no question but that infec- 
tion with tubercle bacilli is to a large extent influenced by social and 
economic conditions; but it appears from available evidence that 
the development of phthisis is almost altogether dependent on these 
factors. Thus, we find among the so-called well-to-do, the cutaneous 
tuberculin reaction only rarely reveals hypersensitiveness in infants 
and children. Schlossmann even says that a positive skin reaction 
is hardly ever found in the children of his rich clientele, indicating 
that they are free from infection. The experience of American physi- 
cians appears to be to the same effect, though we do not have data 
about inoculation of a large series of well-to-do children in this, or any 
other, country. It is, however, a rule among pediatrists to place 
great reliance on the tuberculin test in children. That this is justified 
in the case of children of prosperous parentage may be true, but whether 
in older children a positive skin reaction is exceptional is open to 
question. When children attend school, and later when they go out 
into the world, meeting all sorts and conditions of men, they are no 
longer sheltered against infection, and most of them, in fact, do become 
infected sooner or later. 

The high proportion of positive reactions obtained among children 
and adults in rural districts in Germany and Scandinavia, where 
infection has taken place despite the absence of known open cases of 
tuberculosis, and even where bovine infection could be excluded, appears 
to confirm this view. In fact, it is very rare to find an adult in a 
large city who does not show a positive skin reaction to tuberculin, 
irrespective of his social or economic condition. 

Among the millions of proletariat in large modern industrial cities 
infection appears to be most rampant. All reliable tests — autopsies 
and tuberculin — have shown that very few escape infection, and the 
clinics, sanatoriums, and hospitals for tuberculous patients derive their 
clinical material mainly from these strata of population. A study of 
the mortality-rates also shows that these are the people who are most 
likely to succumb to tuberculosis. One has only to glance over the 
maps of New York City prepared under the auspices of Herman M. 
Biggs to be convinced that poverty and tuberculosis go hand-in-hand. 
The blocks inhabited by the rich show exceedingly few deaths from 
this disease, while those inhabited by the artisans, the laborers, and 
the poor — the " slums" — are appallingly studded with cases of phthisis. 
Poverty, filth, and overcrowding may act by favoring the spread of 
infection, or by reducing the inherent resisting powers. 



SOCIAL AND ECONOMIC FACTORS 73 

Illustrations from other cities are not wanting. In Hamburg the 
death-rates from tuberculosis are in inverse ratio to the amount of 
income tax paid by the various groups of population. In Paris, Ber- 
tillon found that in the very rich district Elysee the mortality from 
tuberculosis is the least in the city; it is somewhat higher in the rich 
Opera district; higher in the very well-to-do district Luxembourg; 
higher yet in the well-to-do Temple district; very high in the poor 
Reuilly district, and highest in the Twentieth Arrondissement, where 
the inhabitants are exceedingly poor. In Glasgow, according to Glaister, 
the mortality is higher among families living in one-room apartments 
than in those who live comfortably in several rooms. In Edinburgh 
A. Maxwell Williamson 1 found that the number of cases of tuberculous 
disease increases in proportion as the house accommodations become 
limited. " Pulmonary tuberculosis is a disease which in 70 or 80 per 
cent, of cases occurs in houses of three rooms and under; the number 
of cases is larger in two-room houses than in three; larger in houses 
of one room than in two; and the number of cases of the disease 
increases almost in direct proportion to the number of small houses 
in any district or ward of a city." The relation of phthisis to 
overcrowding is seen clearly in the industrial cities of the United 
States. 

Similar investigations as to the relations of wages to morbidity 
and mortality of tuberculosis have shown that higher wages mean less 
of the disease (see p. 77). The experience of life insurance companies 
is to the effect that industrial policyholders, who pay small weekly 
premiums, are more likely to succumb to the disease than those who 
hold " ordinary" policies paying annual premiums. In Europe it has 
been observed that the larger the amount for which the person is 
insured, the less likely he is to succumb to tuberculosis. 

The influence of poverty on the incidence of tuberculosis has been 
demonstrated recently in the countries affected by the war, directly 
or indirectly. The mortality has increased wherever the cost of living 
went up — in Germany, Austria, France, England, etc., and also in the 
Scandinavian countries, in Holland, in Brazil, and Argentine. Scarcity 
of nourishing food, and its high cost, producing undernutrition even -in 
those who ordinarily have plenty, is undoubtedly the agent. Similar 
conditions were observed in the City of Paris during the Siege in 
1870-71 in an even more accentuated form. 

The slums of large cities contain "lung" blocks which have been 
pictured in such sombre colors in the popular tuberculosis literature. 
Of course, the bad housing conditions are responsible to a large extent. 
But it must be remembered also that " a slum is not constituted solely 
of broken-down houses, but also of broken-down occupants, and it is 
perhaps easier to remedy the one than the other," says John Glaister. 2 
Moreover, the tuberculous, unable to earn a living, are more likely to 

i British Jour. Tuberc, 1915, ix, 111. 
2 Practitioner, 1913, xc, 344. 



74 THE EPIDEMIOLOGY OF TUBERCULOSIS 

move into cheap, i. e., unsanitary, dwellings. This is a factor which is 
not generally appreciated when slums and "lung blocks" are spoken of. 

Thus, we have a vicious circle in the economics of tuberculosis. 
Poverty brings about congestion and overcrowding, enhancing the 
chances of massive infection; it also compels its victims to work in 
unsanitary factories, mills and workshops and at trades which are 
dangerous in this regard. The vitality is depressed and the powers of 
resistance reduced as a result of insufficient and improperly prepared 
food, so that infection more often terminates in phthisis than among 
those who are higher in the social scale. 

However, that the well-to-do and rich do not escape is evident when 
we glance into the modern private sanatoriums, w T hich derive their 
clientele from those who can pay more than fifty dollars per week, 
not including medical attendance. The resorts in Europe are also 
filled with rich consumptives, as can be seen in Switzerland and the 
Riviera. Of course, this shows that not all well-to-do individuals 
live wisely, even though they can well afford to do so. 

Influence of Age. — In considering the influence of age on the inci- 
dence of tuberculosis we must again differentiate tuberculous injection 
from morbidity and from mortality, and also the various forms of the 
disease. 

The newborn infant is free from tuberculosis, as we have shown; 
infection takes place during the lifetime of the individual who is exposed 
to the bacilli. We have already seen that those living in a tuberculous 
milieu do not escape, and during the first year about 15 per cent, are 
infected; during the first five years, about 50 per cent., and at the age 
of fourteen, over 80 per cent, are infected. Even children of non- 
tuberculous parentage are infected w T ith tuberculosis to the same 
extent as those of tuberculous stock, but not at such an early age, 
and when reaching adolescence the difference is not so pronounced 
as would be expected a 'priori. 

The morbidity from the disease is greatly influenced by age. During 
the first two years of life tuberculosis is very frequently encountered 
in the form of acute miliary tuberculosis, and tuberculosis of the joints, 
bones, and glands. Between two and ten years of age we mostly 
find the milder forms of osseous, glandular, and articular tuberculosis, 
and chronic pulmonary tuberculosis is very rare. Only after the age 
of ten does the latter form of tuberculosis make its appearance, and 
after fifteen years of age it becomes the menace of society — the pro- 
verbial " white plague" — causing more misery than any other dis- 
ease. 

The disease is, however, for lack of reliable morbidity statistics, best 
gauged by a study of the mortality-rates. From the table on the oppo- 
site page it is seen that there are two maximums of mortality. The first 
during the first two years of life; while beginning with the third year, 
tuberculosis becomes a very infrequent cause of death until the tenth 
year is reached, when it again begins to rise, reaching its full height at 



INFLUENCE OF SEX 



75 



twenty years, and keeps at that high level with slight fluctuations until 
sixty years, when there is again a slight decline. 

Mortality from Tuberculosis in the Registration Area of the United 
States per 10,000 Living at the Given Age and Sex, 1910-1913. 













All other forms of 


Pulmonary tuberculosis. 


tuberculosis. 


Age. Males. Females. 


Males. Females 


Oto 1 6.73 5.68 


13.76 12.14 


1 . 








4.72 4.00 


11.78 10.64 


2 . 








2.14 1.97 


6.13 5.53 


3 . 








1.44 1.41 


3 . 95 3 . 84 


4 . 








1.00 1.16 


2.90 2.78 


5 . 








0.97 0.94 


2.10 1.54 


6 . 








0.92 0^84 


2.01 1.37 


7 . 








0.85 1.19 


1.83 1.95 


8 . 








0.63 1.26 


1.36 2.07 


9 . 








0.98 1.31 


2.11 2.14 


10 to 14 . 








1 . 22 2 . 94 


1.15 1.35 


15 to 19 . 








7.96 11.09 


1.72 2.09 


20 to 24 . 








16.27 17.66 


2.10 2.26 


25 to 29 . 








18.98 19.33 


2.12 2.10 


30 to 34 . 








21.70 18.62 


2 . 08 2 . 01 


35 to 39 . 








23.13 16.22 


2 . 09 1 . 89 


40 to 44 . 








23.47 14.25 


2 . 07 1 . 69 


45 to 49 . 








23.32 11.99 


2 . 02 1 . 63 


50 to 54 . 








21.68 11.19 


2 . 04 1 . 63 


55 to 59 . 








22.99 11.80 


2". 47 1.96 


60 to 64 . 








22.13 12.39 


2 . 56 1 . 92 


65 to 69 . 








21.00 14.25 


2.45 2.22 


70 to 74 . . 








20.11 15.87 


2.68 2.37 


75 to 79 . . 








18.02 16.07 


2.41 2.70 


80 to 84 . 








13.64 13.24 


2.02 2.20 


85 to 89 . 








12.48 10.23 


2.38 2.23 


90 to 94 . 








9.71 6.58 


1.21 1.25 


95 and over 








10.37 6.71 


1.52 



It is thus clear that the rate of infection with tuberculosis does not 
follow closely the rate at which the disease hills. As shown in the table on 
page 66, infection begins during the first year of life, keeps on increasing 
during every subsequent year until at the age of twenty very few indi- 
viduals are found who have escaped it. The mortality is comparatively 
high during the first year of life, but then declines, so that between 
three and twelve years, just the period when most infections occur, 
the number of deaths is the least, and only after the fifteenth year does 
the mortality rise to its highest point, and keeps at it throughout life. 
The bearings of these facts on the problems of phthisiogenesis and 
prophylaxis will appear in other sections of this book. 

Influence of Sex. — From the table on this page we find that during 
the first six years of life the mortality from pulmonary tuberculosis 
is somewhat, though not very materially, less among females than 
among males. After the sixth year the rates among females are higher 
than among males of the corresponding age groups. Between fifteen 
and thirty years of age the difference in favor of the males is striking. 
After thirty years the females again show lower mortality-rates which 
keep up until the end of natural human life. The total mortality is 



76 THE EPIDEMIOLOGY OF TUBERCULOSIS 

less among females than among males, a fact which has been observed 
in all countries where vital statistics are available. In England and 
Wales the mortality from phthisis in 1916 was: Among the total 
population 12.59 per 10,000; among males 16.35, and among females 
only 9.16. 

Various explanations have been offered for this disparity in the mor- 
tality from phthisis between the two sexes. It has been suggested that 
the more hazardous occupations, in which men are mainly engaged, 
reduced their resistance, and predisposed them to phthisis; or when 
becoming sick with the disease, the chances of recovery are less in 
the case of men who have to work for their support, as well as for 
those depending on them. But during the ages of fifteen to forty-five, 



200 
180 
.160 
110 
120 
100 































































































































































'N y 
































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.0 

Fig. 3. — Death-rates per 100,000 population by age and sex in the Commonwealth of 

Australia for the years 1909-1913 (all fcrms of tuberculosis). Males, ; 

females, . 



when menstruation, pregnancies and lactation undermine the resisting 
powers of women, it would be but natural that the mortality from 
phthisis should be high among them. Vital statistics in some countries 
seem to support this view, but in the United States and in the Com- 
monwealth of Australia (Fig. 3) the higher mortality among the 
women keeps up only until the age of thirty, when it again declines as 
compared with the men. 

It appears to me that the higher mortality from phthisis among 
women between fifteen and thirty in the United States is to be attrib- 
uted to the large number engaged in gainful occupations. This is con- 
firmed by the census returns showing that among all classes of popula- 
tion, male and female, ten years of age and over, without regard to 
occupation, the proportion of deaths from tuberculosis is 56 per cent. 



INFLUENCE OF SEX 77 

males, and 44 per cent, females. When women enter gainful occupations 
to earn a living, as B. S. Warren 1 has shown, the proportion is reversed 
and the difference much greater. Thus, among salesmen tuberculosis 
constitutes 15.8 per cent, of all deaths, as against 31.1 per cent, among 
saleswomen; among silk-mill weavers, men 19.7 per cent, and women 
38.3 per cent.; among woollen-mill operatives, males 22.2 per cent, 
and females 29.2 per cent.; clerks and copyists, males 29.2 per cent, 
and females 31.8 per cent.; and boot and shoemakers, males 13.3 
per cent, and females 31.8 per cent. It thus appears that it is more a 
problem of industrial conditions than of sexual differences. In fact, 
women do not bear hard work under deleterious conditions as well 
as men, and succumb to phthisis in greater numbers when, in addition 
to exercising their physiological functions, they become bread-winners. 
Since women entered industrial occupations, their mortality from 
tuberculosis has greatly increased. Thus, in Stockholm, the mortality 
from tuberculosis since 1881 has been in women only two-thirds that 
of men. E. Lindhagen 2 shows that between fifteen and twenty years 
of age the death-rate in women has, however, increased by 18 per cent., 
while that of men has been reduced by 12 per cent. During the World 
War there has been noted an increase in the tuberculosis rates in females 
much more intense than that of the males. In England and Wales 
the following figures show the exact state of affairs: 3 

Deaths from Pulmonary Tuberculosis. 

Males. Females. 

1911 21,985 17,247 

1912 21,568 16,515 

1913 21,034 16,021 

1914 21,812 16,825 

1915 23,630 18,046 

1916 23,238 18,307 

1917 23,670 19,443 

The increase in the mortality from phthisis is shown in the following 
figures, representing the number of deaths which occurred above those 
reported for 1913: 

Males. Females. Total. 

1914 : .... 728 804 1562 

1915 2596 2025 4621 

1916 2204 2286 4490 

1917 2636 3422 6058 

Per million population the mortality from phthisis in England and 
Wales has increased from 1571 in 1911-1914, to 1888 in 1915, and 2035 
in 1916. 

In Netherlands similar conditions have been observed. B. H. Sajet 1 
shows that in cities the tuberculosis death-rates have increased since 

1 Tr. Nat. Assn. Study and Prevent. Tuberc, 1913, ix, 153. 

2 Hygeia, 1918, lxxx, 497. 

3 Newsholme: Lancet, 1917, ii, 591. 

* Nederl. Tijschr. ven. Genaec, 1917, p. 1859. 



78 THE EPIDEMIOLOGY OF TUBERCULOSIS 

the war from 154.4 per 100,000 in 1913 to 179.5 in 1916. The mor- 
tality has, however, not increased materially among young men in 
the cities, but there has been noted a great increase among the women 
between twenty and thirty years of age, i. e., among those of working 
age. Similar conditions have also been observed in other belligerent 
countries, and in those in which the labor market has been affected 
by the war. It is not only the reduced food supply and the increased 
cost of living that are responsible for this increase, but also the fact 
that women, who formerly were idle, or engaged in less dangerous 
trades, now had to go to work at all kinds and conditions of labor, and 
thus their mortality from the most important of industrial diseases 
has increased. 

Mortality-rates from Pulmonary Tuberculosis. — It is impossible 
at present to give with certainty the extent of tuberculous morbidity 
in any population. Even in cities where registration of this disease 
is compulsory, the data collected in this manner are not complete, 
and we do not know the exact number of persons suffering from active 
tuberculosis. The statistics published by certain benevolent and indus- 
trial societies are also inconclusive because they concern only certain 
groups of people, and the results cannot be applied to the general popu- 
lation. Attempts have been made to ascertain the morbidity-rates 
from tuberculosis by multiplying the number of deaths occurring 
in a given region by the average duration of the disease. Thus, there 
annually occur about 160,000 deaths due to tuberculosis in the United 
States; in Germany over 100,000; in France 70,000; in England and 
Wales ovei 50,000, etc. But attempts at multiplying these numbers 
by the number representing the average duration of the disease and 
thus finding the actual number of sick have met with failure because 
there is no agreement as to the average length of phthisis. Indeed, 
it has been estimated at from one to ten years by different authors. 

The extent of the disease is therefore best gauged by the number 
of deaths it causes in a given population. The table on page 69 gives 
the mortality per 100,000 population in different countries. When 
in connection with these figures we bear in mind that one-third of 
all the deaths during the prime of life, between fifteen and forty, are 
due to tuberculosis, of which over 90 per cent, is phthisis, we realize 
the enormity of the problem presented by tuberculosis and the reason 
why it has been considered the most important of diseases with which 
humanity has to cope. 

Statisticians are, however, inclined to question the accuracy of the 
tuberculosis mortality statistics. Some state that many persons dying 
from other pulmonary diseases, notably bronchitis, pneumonia, typhoid, 
cerebrospinal meningitis, influenza, etc., as well as many other diseases, 
which occur in consumptives as often as in others, are reported as hav- 
ing died from these diseases, though the real cause of death was un- 
doubtedly phthisis. This point is well illustrated in the mortality- 
rates in Italy. During 1896-1901 only 1060 per million died from 
tuberculosis in Italy as against 1911 in Switzerland. But in Italy 



DECLINE IN THE MORTALITY FROM TUBERCULOSIS 79 

during the same period there were reported as having died 2032 from 
bronchitis, 2031 from pneumonia, and a total of 4641 deaths per 
million from various diseases of the respiratory organs. In Switzer- 
land during the same period the rates were: Bronchitis, 1092; pneu- 
monia, 1525, and all respiratory diseases, 2828. Similar figures may 
be culled from the Registrar's Officers' reports in many other countries. 
This is also to be seen from the fact that in cities in which compulsory 
registration of tuberculous patients is enforced, a large proportion 
who are reported tuberculous are in the end certified as having died 
from other diseases, which is undoubtedly true, because tuberculous 
patients are liable to other fatal diseases, but still, while alive, they 
were tuberculous and sources of infection. It has been my observation 
that in populations in which so-called "industrial insurance" is com- 
monly taken out by the poorer strata of the people, tuberculosis is 
often not given as the cause of death, because it may interfere with 
the collection of the death claims from the insurance companies. It 
is also a fact that since tuberculosis has become an actual stigma, 
some deaths due to this disease are returned as having been caused 
by other diseases with a view of sparing the families the feeling of 
"tainted blood." 

The differences in the mortality-rates for the various countries are 
due to diverse causes, mainly the intensity of concentration of popu- 
lation in cities, the character of the occupations pursued by the people 
and other factors which have already been discussed. 

Decline in the Mortality from Tuberculosis. — Another point brought 
out by the figures in this table is that the mortality from tuberculosis 
has been declining in nearly all countries where statistics are available, 
excepting in Norway, Ireland, Serbia, Spain, France, Italy, Japan, 
Hungary, etc. This decline is of great significance, and if the exact 
causes were ascertained we might be in a position to accelerate it, so 
that ultimately the disease could be stamped out altogether. 

In England the decline in the tuberculosis mortality can be traced 
back for 150 years. "In the years 1743-53," says Arthur Ransome, 1 
"when, as Ogle says, 'there were fairly accurate transcripts from the 
parish registers, the proportion of deaths was rather more than one- 
fifth; and, in the first returns of the Registrar-General, in 1838, in 
London, it was 1 to 6 or 8.' In other words, the rate per thousand 
deaths in the former period was about 200, and in the latter about 
148. Hence, in the middle of the eighteenth century, phthisis must 
have been still more common than in 1838; and then the diminution 
in the mortality from the disease must have been proceeding steadily, 
at about the same rate as that observed in the earlier years." A 
glance at Fig. 4, showing the mortality in 1851, as compared with 1912, 
proves conclusively that the mortality has declined. The same is true 
of Scotland, Australia, Germany, Austria, etc. For the United States 
Frederick L. Hoffman's 2 statistics tend to show that the mortality 

1 Tr. Epidemiol. Soc, London, 1904-05, xxiv, 259. 

2 Tr. Nat. Assn. Study of Prevent. Tuberc, 1913, ix, 101. 



80 



THE EPIDEMIOLOGY OF TUBERCULOSIS 



from tuberculosis in New York, Philadelphia, Boston, etc., has been 
constantly declining during the past one hundred years. 

What are the causes of this decline in the tuberculosis mortality? 
All authorities agree that it is mainly due to the causes which have 
been operative in reducing the general mortality; in banishing, or 
abating, the malignancy of most other infectious diseases. Among 
these factors are largely to be " considered the improvements in the 
sanitary and hygenic conditions under which the bulk of the people 
live at present. It is also to be considered that modern factory legis- 
lation, the improvements in the economic conditions of the people, 
the shorter hours of work, etc., which are characteristic of the present, 
as compared with conditions during the first half of the nineteenth 



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Fig. 4.— Mortality from phthisis by age groups in England and Wales per 10,000 
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century, have been instrumental in reducing the general mortality 
and of phthisis as well. Wages have been increasing, and the food 
consumed by the working people of today is much superior to that 
which they could afford fifty or one hundred years ago. The distribu- 
tion of food, as well as its preservation, precludes famines at present. 
An increase in the tuberculosis-rates is often observed during and 
after famines. 

The Effect of the Special Campaign against the Spread of the 
Disease. — Most authors, when speaking of the reduction in the tubercu- 
losis mortality, point at once at the special measures which have been 
taken to combat this disease as the sole factor in this direction. In 
fact, the figures compiled in the tables on pp. 69 and 70 are always 
brought forward in proof of the effectiveness of the antituberculosis 
campaign which has been so aggressively waged. 



SPECIAL CAMPAIGN AGAINST THE SPREAD OF DISEASE 81 

But careful studies of the available statistical data have not sus- 
tained this contention. In England, where the decline has been more 
pronounced than in any other country, it has been shown by competent 
statisticians that such is not the fact. Karl Pearson 1 points out that, 
examining available data, it appears that the death-rates from phthisis 
are steadily increasing as we go backward to 1838; according to Arthur 
Ransome even as far back as 1743, as was mentioned above. Now, 
this could not go on indefinitely because if it did, every individual five 
hundred years ago must have died in England from phthisis. There 
was assuredly a time in England when the phthisis rates were rising, 
just as they have recently been falling. "We have to stretch," says 
Pearson, " our ideas of time a little and we should realize the possibility 
of a typical epidemic curve in the frequency of phthisis. Indeed, the 
mortality from phthisis in England has been declining since 1838, 
i. e., long before any special measures had been taken for the control 
of the disease, or segregation of the sources of infection — tuberculous 
human beings and animals — had been attempted." 

Data from other countries, especially where the disease has become 
a menace during recent years, confirm these views. During the first 
half of the nineteenth century there were isolated areas in Europe 
where tuberculosis was rare, but with the segregation of the popula- 
tion in cities during recent years, and the introduction of modern indus- 
trial conditions, the disease has made its appearance, and rages there 
with greater vigor than in countries where the disease has appeared 
before. Thus, the tuberculosis mortality has been rising in Ireland, 
Norway, Serbia, Bulgaria, Hungary, Japan, etc., during the very 
period that it has been declining in England, Germany, etc. There 
is no doubt that the measures taken for the control of the disease in 
Norway are as aggressive and advanced as those taken in neighboring 
Denmark, yet in the former the mortality-rates have been rising, while 
in the latter they have steadily declined. The same is true of France 
when compared with Belgium, and similar analogies can be made 
between other countries, or various regions of any single country. 

It appears that the mortality-rates from tuberculosis have been declin- 
ing to the same extent as the general mortality from all causes, as has been 
shown clearly by many competent statisticians. Professor Walter F. 
Wilcox 2 says that "to show that the campaign against tuberculosis is 
having its effects, it should be found that the death-rates from that 
disease are decreasing faster than the average for all other causes." 
But a test of this question with statistics for the mortality in the State 
of New York shows that the result is a negative one. "No influence 
of the special campaign can be traced in the figures. The condition 
in Michigan is similar to that in New York. In Indiana the number 
of deaths in each instance had decreased, but apparently the propor- 
tion of those from tuberculosis to all others has not." In New Jersey 
and Rhode Island, while the mortality from other causes has been 

1 The Fight against Tuberculosis and the Death-rate from Phthisis, London, 1911, p. 9. 

2 Monthly Bulletin New York Board of Health, 1910, xxvi, 85, 

6 



82 THE EPIDEMIOLOGX OF TUBERCULOSIS 

decreasing, that from tuberculosis has been increasing, so that the 
comparative proportion of the latter has risen. Pearson has proved 
incontrovertibly that since the campaign has been waged in England 
against tuberculosis "the rate of fall in the death-rate from phthisis, 
instead of being accelerated, has been retarded." 

Statisticians are not alone in this opinion. In a posthumous paper 
by Robert Koch 1 he states that the special measures taken for the 
control of tuberculosis, such as segregation of consumptives, the erec- 
tion of sanatoriums, etc., are not to be taken as the sole factors which 
have been instrumental in reducing the mortality from tuberculosis 
during recent years. He says: "Many have connected the decrease 
in the tuberculosis mortality with the discovery of the tubercle bacillus. 
It was stated that since proofs have been produced that tuberculosis 
is transmissible, greater care has been taken to prevent infection, 
while before the discovery of the tubercle bacillus physicians, and 
with them the laity, denied the transmissibility of the disease. This 
assumption surely has something in its favor. At any rate, it is a strik- 
ing fact that, with but few exceptions, the decline in the mortality 
began a few years after the discovery of this bacillus. But just these 
exceptions prove that the newly engendered fear of the dangers of 
infection is not the only factor operative in this direction, although 
we must give it a certain, and not an inconsiderable, amount of credit. 
Among German authors we often meet with the view that the recent 
social legislation, especially that concerning workmen's insurance, has 
been effective in reducing the tuberculosis mortality. To a certain 
degree there is some correlation in time between these two phenomena 
in Germany. But, inasmuch* as in most other countries such laws 
have not been inaugurated and the decline in the tuberculosis mor- 
tality has taken place to the same extent as in Germany, this factor 
should also not be taken as a cause." 

In this country we now hear similar opinions expressed. William 
Charles White 2 says: "We cannot possibly avoid the facts that in 
spite of all our labor our results are not what we might have expected 
on a right premise; for our reduction in morbidity and mortality 
from tuberculosis has not kept pace with the reduction in the general 
death-rate; and, further, our reduction in mortality was about as great 
before we started our present methods, and in proving how great the 
influence of our efforts has been we usually neglect all the influences 
that operated before we began, and new factors, such as the Mills- 
Reinecke phenomenon, and ascribe all good to our own work." 

Real Causes of the Decline in the Tuberculosis Mortality.— Careful 
study of the economic and social conditions in the various countries 
where statistical data are available shows clearly that there is a pro- 
nounced correlation between urbanization, i. e., concentration of large 
masses of population in cities, and the death-rates from phthisis. 
Wherever the process of urbanization is new, wherever modern indus- 

» Ztschr. f. Hyg., 1910, lxvii, 1. 

* Tr. Nat. Assn. Study and Prevent, of Tuberc, 1913, ix, 80, 



CAUSES OF DECLINE IN TUBERCULOSIS MORTALITY 83 

tries have only recently been introduced, and large numbers of rural 
population have been attracted to cities, the death-rates from phthisis 
have been rising. This is the case in Japan, Norway, Ireland, Serbia, 
Bulgaria, etc., and to a certain extent in Russia, Austria, Italy, France, 
etc., where the mortality has not decreased perceptibly. On the other 
hand, in England, where industrial development was operative in 
the beginning of the nineteenth century, it was at that time that 
the high phthisis mortality occurred and it began to decline with the 
adaptation of the people to city life. For this reason the negroes in 
the cities in the United States, though they have a high phthisis mor- 
tality, and no special measures are taken to prevent dissemination 
of the disease among them, also show a strong tendency toward a 
reduction in the death-rates. Thus, in Baltimore, John W. Fulton 
found to his amazement that " both races gained against tuberculosis, 
the whites at the rate of 30.8 per cent., and the negroes at the rate of 
24.5 per cent, in the decade of 1904-1913." 

We have already shown that whenever people who have hitherto 
been free from tuberculosis meet with tubercle-laden surroundings, 
they succumb to the more acute and fatal forms of the disease, while 
most of those who have for generations been tuberculized are either 
not harmed by infection at all, phthisis not developing after the vast 
majority of infections, or when it does develop, it manifests a tendency 
to pursue an exceedingly chronic course, or heals spontaneously in a 
large number of cases. The reasons for this phenomenon will be dis- 
cussed under the heading of Phthisiogenesis (see Chapter V). 

The decline in the mortality cannot be attributed to any single cause, 
but is apparently due to many and complex factors, most of which 
are obscure at the present state of our knowledge. It seems, however, 
that recent improvements in the social and economic conditions of the 
working classes, the inauguration of general hygienic and sanitary 
measures, and above all the improvement in the housing conditions 
and in the quantity and quality of the food consumed by the working 
classes, who are the main candidates for consumption, have all been 
of assistance in this direction, although the adaptation of the organism 
to city life, and to the tubercle bacillus, is perhaps of greater importance 
than all other factors taken together. We must never forget in this 
connection that the modern methods of prevention aim at but one thing : 
the prevention of infection. And in this they have utterly failed, as 
they should if we consider that hardly 5 per cent, of the open cases 
of tuberculosis have been isolated. There could not have been more 
than 90 per cent, of humanity with tuberculous lesions in their bodies 
as we find at present while making autopsies; there could not have 
been at any time many more than 75 per cent, of humanity in cities 
showing conclusive evidence of having been infected with tubercle 
bacilli when tested with tuberculin. But what has been achieved is 
a reduction in the morbidity, and especially in the mortality from 
phthisis even in those who, despite all our efforts at prevention, have 
been infected with the virus. 



CHAPTER IV. 

FACTORS PREDISPOSING TO THE EVOLUTION OF 
PHTHISIS. 

We have seen that tuberculosis is a highly transmissible disease; 
that bacteriological, pathological, and clinical evidence combine to 
prove that hardly anybody exposed to tubercle bacilli escapes infec- 
tion. The only difference of opinion among authorities at present appears 
to be whether as many as 95 per cent, of civilized humanity show evidence 
that the tubercle bacilli have been implanted in some organs of their bodies, 
or merely 70 per cent. It is now important to inquire why only 10 or 
12 per cent, of humanity succumb to this disease while nearly 90 per 
cent, either remain in good health or suffer from, or succumb to, other 
diseases, in spite of tuberculous infection of which they show undoubted 
traces. "If, of a large number of persons exposed to infection and 
infected," says Kingston Fowler, "only a few acquire the disease, the 
susceptibility becomes a factor in causation of greater moment than 
exposure to infection." 

Tuberculosis is not a clinical entity like typhoid fever, pneumonia, 
or smallpox, running a certain and definite course, at times severe, 
often mild, but always producing the same clinical picture. Tubercu- 
losis in children produces a different clinical picture from that in adults. 
In the former it is usually a bacteremia, affecting the glands, bones, 
joints, etc., while in the latter it is a local chronic disease of the lungs 
— 95 per cent, of tuberculosis in adults is phthisis pulmonum. How are 
these phenomena to be explained? Even the evidence which tends 
to show that milk from tuberculous cattle is responsible for the mild 
forms of tuberculosis in children, while the human type of bacilli is 
responsible for the phthisis in adults, and the graver forms in children, 
is insufficient to explain all these remarkable phenomena. The fact 
that adults consume the same milk is, among others, proof that there 
are other factors operative in phthisiogenesis. 

Another important problem in phthisiogenesis is why do those 
affected with tuberculosis of the lungs show such different proclivities 
to suffer as a result of infection with the same type of bacillus? Clinic- 
ally, we find that some are attacked with the acute forms of the disease, 
such as acute general miliary tuberculosis, acute pneumonic phthisis, 
etc., and succumb in a relatively short time; others suffer from sub- 
acute phthisis, which may progress slowly, or rapidly, to a fatal termi- 
nation, or suddenly take a turn for the better and run a chronic course, 
without any apparent reason to account for the change in the malig- 



INTENSITY OF THE INFECTION 85 

nancy of the disease; in still others the disease begins insidiously, 
runs a slow, sluggish course for many years, incapacitating the patient 
now and then for a variable period, yet he lives indefinitely, perhaps 
his natural life, and may die from some intercurrent disease. To these 
must be added the large, in fact the enormous, number of persons 
in whom the implantation of the tubercle bacilli in the lungs, or any 
other organ, produces anatomical changes in structure unmistakably 
recognizable at the necropsy; yet these lesions heal spontaneously, 
the patient and his physician knowing nothing about the morbid 
phenomena of tuberculosis during the life of the individual. 

What are the factors which endow this last class of persons, who 
are in the majority among the living, with resisting power that the 
implantation of tubercle bacilli in their bodies, though causing structural 
changes in their lungs, does not in the least affect their general health? 
Which are the factors that predispose others so that when the bacilli 
are implanted in their bodies the disease runs an acute or subacute 
course and they sooner or later succumb to the action of these micro- 
organisms and their toxins? 

Intensity of the Infection. — Our experience with most microbic 
diseases has shown that the average animal organism can withstand the 
entry of a certain minimal dose of bacilli without developing disease. 
In experimental tuberculosis it has been found that small doses of 
bacilli are less likely to kill than larger doses. Cobbett found that small 
doses of bovine tubercle bacilli, when injected into calves, produce 
only localized and limited lesions which soon became fibrous and 
calcareous, and thus assumed a retrogressive type; while the animals 
themselves, after a transient disturbance of health, remained in excel- 
lent condition up to the time when they came to be slaughtered and 
examined. Medium doses (10 mg.), on the other hand, produced 
irregular results, while larger ones (50 mg.) invariably caused general- 
ized tuberculosis which, in all but few animals (6 per cent.), proved 
fatal within a few weeks or months (17 to 76 days). Gilbert and Gregg 
found that it requires between 10 and 120 bacilli to infect a guinea-pig. 
Webb and Gilbert found that this number of bacilli were sufficient to 
cause infection in a human child. H. J. Corper showed that the sub- 
cutaneous injection of 0.000,001 mg. of moist culture produced tuber- 
culosis in a guinea-pig within two months, while smaller doses usually 
produced only local lesions. Large doses produced multiple foci in 
various parts of the body. 

We would be rash in concluding that such large doses as would be 
required to infect experimentally an animal of the size of a human 
being is rarely, if ever, inhaled even in the presence of a coughing con- 
sumptive, and for this reason most cases of infection prove to be 
harmless — the dose is too small to produce disease. But we know that 
the bacilli multiply in the human body, and the few introduced may, 
finding suitable conditions for life, proliferate and produce disease of 
any magnitude. Cobbett is inclined to attribute the harmlessness of 



86 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

small doses of bacilli to the following factors: After a minimal dose of 
bacilli enter the body, the organism at once begins to mobilize and 
develop its protective forces which are sufficient to deal with a few 
bacilli, while when a large number are introduced, it may overwhelm 
the natural protective forces. This is confirmed to a certain degree by 
clinical observations in children. Most are infected with slight doses 
of tubercle bacilli in early life, and are hardly harmed by the infection. 
A small proportion, particularly those subjected to massive infection, 
succumb to acute tuberculous disease. The mild infections enhance 
the work of the protective apparatus and prevent the multiplication 
of the bacteria; large doses can cope with the slight amounts of im- 
munizing bodies which they provoke, and can keep on multiplying 
and destroying vital tissues. 

This may explain the immunity of children living in modern com- 
munities in which tubercle bacilli are ubiquitous. But it does not 
explain the development of phthisis in the adult who has been infected 
in early life with minimal doses of tubercle bacilli which remained 
latent for many years. The latter has been explained by the theory 
of predisposition, or diathesis, the innate, inborn tendency of certain 
persons to acquire diseases which depends on certain peculiarities of 
the structure and function of the body. Acknowledging that Allen 
K. Krause is justified in saying that predisposition u really explains a 
lot if you have outlived your youthful insistence for sharpness, clarity, 
and definiteness," we shall proceed to inquire into the various theories 
of predisposition and resistance. 

Theories of Predisposition. — From the numerous theories which 
have been advanced the following are worthy of discussion: 

1. Some have seen in the predisposition of patients an expression 
of heredity; that there are families who are exceedingly predisposed 
to the action of the tubercle bacilli, while others possess more or less 
resistance in this regard. In the former, infection is followed by 
phthisis, or tuberculosis of some other organs, which may be mild or 
severe; while in the latter, infection is merely followed by a change 
in the biological properties of the blood as can be seen from their 
altered reactivity to tuberculin. 

2. Others have attributed the predisposition to phthisis to con- 
stitutional biochemical or serological derangements of the body, or 
the blood. There have even been suggested methods of treatment 
of the disease along the lines of removing the constitutional defects, 
and thus preventing or curing the disease. 

3. Finally, others have maintained that the predisposition to phthisis 
depends on certain local anatomical peculiarities of the lungs, or the 
thoracic skeleton, which reduce the vitality of this respiratory organ 
and thus favor the proliferation of the bacilli which may have been 
brought there by the ah* or circulating blood. 

We shall discuss these theories in some detail. 



ttEREblTV 87 



HEREDITY. 



Lack of Reliable Statistics on Heredity of Phthisis. — The theory 
of hereditary predisposition may be supported by either statistical data 
about ancestral tuberculosis, or by biological observations in diseased 
organisms. 

For centuries physicians have noted that in certain families tuber- 
culosis reappears in successive generations, and many patients can 
trace the disease back to their ancestors and blood relatives. Statistics 
collected along these lines are plentiful, but on close analysis it appears 
that they are of little value in proving or disproving the hereditary 
transmission of the disease, or of a predisposition to it. 

Even disregarding the ubiquity of the disease, one out of every 
seven or eight deaths is due to it, so that it may be found in any 
large family or its branches, it must be borne in mind that the average 
history of a tuberculous patient who is derived from uneducated 
social classes is very unreliable. The statements about the state of 
health, and especially the causes of death, of grandparents, parents, 
brothers and sisters are open to criticism in the vast majority of cases. 
Even the questions about their personal history are not accurately 
answered, as a rule. Our patients at the Montefiore Hospital nearly 
all state that they had measles during childhood, probably on the 
principle that everyone must have it. But very few say that they 
have had diphtheria, typhoid, typhus, scarlet fever, etc., although 
most of them come from eastern Europe where these diseases are 
rampant and hardly any attempts are made to check them by proper 
quarantine regulations, and very few indeed escape. Very few know 
the cause of death of their parents, hardly any that of their grand- 
parents; in fact, it would seem as if their parents were all immune to 
phthisis, considering that the patients do not mention it after questions 
are addressed to them on the subject. 

In private practice, where we deal with a more intelligent class, we 
often find that the father has coughed, the mother had hemoptysis, etc., 
after a categorical answer that there has been no consumption in the 
family. On the other hand, we know how much suggestion through 
leading questions suitable for a certain theory may bring out appro- 
priate answers. Many patients are convinced that their blood is not 
by any means "tainted," that they "come from healthy stock," that 
"there has never been any consumption in their family," etc. 

To prove statistically the hereditary transmission of tuberculosis, 
or a predisposition to the disease, carefully kept records of many 
families would be required , in which children of tuberculous parentage 
have succumbed to the disease despite the fact that they have been 
removed immediately after birth, thus preventing exposure to infec- 
tion through intimate contact. This we do not have. Even the data 
given by orphan asylums, showing that thousands of children of tuber- 
culous parentage do not develop tuberculosis, are of absolutely no 



88 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

value in disproving heredity of this disease. In these institutions 
children under fourteen are usually kept, and at that age active phthisis 
is exceedingly rare, as has already been shown. 

For these reasons very little confidence can be placed in the statis- 
tical compilations of various authors to the effect that among their 
patients 25, 44.7, or 59.2 per cent, have given a history of tuberculosis 
in the parents, grandparents, brothers, sisters, or collaterals. It de- 
pends a great deal on the zeal of the questioner to obtain points for 
the substantiation of his pet theory. Even the excellent statistical 
studies of Karl Pearson, Weinberg, Schluter, and many others are not 
at all convincing. In fact, M. Burckhardt 1 has found that in non- 
tuberculous persons tuberculosis in ascendency is just as strongly 
represented as in the tuberculous, and that the disease in the father is 
just as frequent in both groups, while the frequent occurrences in the 
mothers, fathers, brothers, sisters, uncles, and aunts can easily be 
explained by infection. 

Germinative Transmission. — The reappearance of tuberculosis in 
several successive generations is by no means proof that the disease 
has been transmitted by heredity, nor even that the so-called predis- 
position to the disease has been inherited. In coal miners the lungs 
show changes of anthracosis through several generations, so long as 
they are engaged at that occupation. But no one will say that it 
has been inherited. Similarly, the social, economic, hygienic, and 
sanitary conditions and surroundings which were responsible for 
phthisis in the parents may be, and usually are, operative in the chil- 
dren who remain in the same social milieu. We may justly speak of 
social heredity, but not of biological heredity. The latter implies the 
transmission of characters, or their physical foundation, which were 
contained in the germ plasm, or the parental sex cells. Anything that 
may affect the fertilized ovum, or affect the embryo, cannot be con- 
sidered inherited, because intra-uterine infection and germinative 
transmission of a disease have nothing to do with the problems of 
heredity, just as extra-uterine influences cannot be considered trans- 
missible. 

Experimental investigations by Friedmann show that intra-uterine 
infection with tubercle bacilli is not impossible. This, in some measure, 
confirms Baumgarten's theory to the effect that tubercle bacilli may 
enter the blood stream of the fetus, remain dormant for a long period 
of years, to flare up again by intense multiplication when, for some 
reason, the natural resistance of the body fails. This form of trans- 
mission of phthisis cannot strictly be considered germinative heredity 
— it is actually infection of the fetus from the mother — yet it is impor- 
tant for the clinician, especially to one giving thought to prophylaxis. 

Baumgarten 2 bases his theory mainly on experiments with tuber- 

1 Ztschr. f. Tuberk., 1904, v, 29. 

2 Arb. a. d. Gebiet. d. Path. Anatom. u. Bakteriol., 1891-1892, vol. i; Lehrbuch d. 
pathogenen Mikroorganismen, Leipzig, 1911, p. 710. 



HEREDITY 89 

culous chickens. It is well known that the progeny of tuberculous 
chickens is tuberculous even under conditions when infection after 
the egg has been laid can be positively excluded. Experimentally it 
has been found that the albumen of a fertilized egg may be inoculated 
with tubercle bacilli, and the evolution of the chick goes on as usual; 
but it develops tuberculosis after it is hatched. This has been done 
by Baumgarten, Milchner, Gartner, MafTucci, Koch, and others. 
Germinative, or placental, transmission of tuberculosis in which the 
female ovum, or the male cell, or the complete embryo, is infected 
through the placental circulation with tubercle bacilli, yet keeps on 
developing, has been proved by other observations, notably in cases 
in which the newborn infant was found tuberculous. Many such 
cases have been reported during recent years as occurring in cattle, 
and also in human beings. In fact, localized, calcareous degeneration 
of some focus in the lungs has been found in newborn infants, showing 
that they had tuberculosis in utero and that the lesions healed. 

We are in the dark as to how these bacilli reached the embryo. Some 
have claimed that the female ovum may be infected with tubercle 
bacilli. Westermeyer, Jani, Jackh, and others have found tubercle 
bacilli in the human ovary and Spano, Porter, Friedmann, and others 
have found them in the semen. To be sure, these findings were mostly 
in persons dead from acute miliary tuberculosis, but it must be borne 
in mind that individuals with genital tuberculosis often cohabit with 
the opposite sex and pregnancy is frequent. Indeed, Albrecht, Cav- 
agnis, Maffucci, and others have succeeded in infecting rabbits and 
guinea-pigs with semen taken from bulls suffering from tuberculosis. 
Friedmann 1 injected an emulsion of tubercle bacilli into the vagina 
of rabbits immediately after they had been impregnated by the male. 
Subsequent observation showed that while the mothers remained free 
from disease, tubercle bacilli were found in sparing numbers in the 
seven-day-old fetuses, which were not at all hampered in their evolu- 
tion. In newborn rabbits whose mothers were thus treated, tubercle 
bacilli were found in various organs. This tends to prove that sper- 
matogenic infection — i. e., infection with tubercle bacilli brought along 
with the semen from a tuberculous father — is possible. 

But, as has been pointed out by Romer, it can be stated that, in 
general, semen contains tubercle bacilli only when the genital organs, 
especially the testicles, are affected. But this does not prove that 
spermatozoa, or the ova, are infected with tubercle bacilli. The size of 
the mammalian ovum and spermatozoon renders it extremely improb- 
able that they should become infected with these germs. In fact, it 
may be stated that no one has ever seen a spermatozoon, or an ovum, 
in which a tubercle bacillus could be discerned. Moreover, even if they 
were infected, they surely could not develop; even if they were not 
killed, they would undoubtedly become sterile. The fact that semen 

i Ztschr. f. klin. Med., 1901, lviii, 2. 



90 FACTORS PREDISPOSING TO EVOLUTION OP PHTHISIS 

occasionally contains tubercle bacilli, as has been shown by its poten- 
tiality to infect animals when injected, does not prove that germinative 
infection takes place. Clinically we often see children born to fathers 
with tuberculous epididymitis are well and remain so. Indeed, there 
is no case reported in which a father with tuberculous epididymitis 
has begotten a congenitally tuberculous child. Even conceding that 
the sperm may carry tubercle bacilli, and thus infect the ovum, it must 
be exceedingly rare, considering that with each emission millions of 
spermatozoa are expelled, and that the one on which a bacillus has im- 
planted itself should be just the one that fertilizes the ovum, is a rather 
remote chance. This mode of infecting the ovum may therefore be 
left out of consideration. 

Placental Transmission. — But there is another possibility, namely, 
intra-uterine infection of the healthy fetus from a phthisical mother 
during pregnancy; the tubercle bacilli entering by way of the placental 
circulation. That the placenta may harbor tubercle bacilli is well 
known; the frequent bacteremia in phthisis explains it. Lehmann, 
Runge, Nowack, Auche, Chamberland, Warthin, Weller, and many 
others have found tubercle bacilli in the human placenta. On carefully 
examining the histology of the placenta of phthisical pregnant women, 
Schmorl and Geipe 1 found tubercle bacilli in 9 out of 20 cases. In 1 
of the 9 the mother had merely an incipient apical lesion. Schmorl 
estimates that 50 per cent, of pregnant phthisical women have tubercle 
bacilli in their placentas. He maintains that tubercle bacilli may enter 
the placenta during any period of pregnancy, and in any stage of the 
disease, but that they are mostly found in the advanced stages of 
phthisis and in acute miliary tuberculosis. The fetus may be infected 
from the mother during the act of birth, when vigorous contractions 
of the uterus may lacerate some of the less resisting parts of the 
placenta. Infection of the fetus may also occur earlier. That they 
should enter directly into the fetus is a remote probability, if at all 
possible, but the bacilli may be brought to the fetus by the blood 
through the umbilical vein; or by way of the intestine after they 
have reached the amnionic fluid and are then swallowed or aspirated 
by the fetus. 

Congenital Tuberculosis. — One way of investigating the problem of 
heredity in tuberculosis is to ascertain the frequency of congenital tuber- 
culous disease. Of these rather few cases have been found, and of those 
reported, only a small proportion can be considered really cases of 
congenital disease. The first undoubted case was reported by Schmorl 
and Birch-Hirschfeld. 2 The mother died from general miliary tuber- 
culosis in the seventh month of pregnancy. The placenta appeared 
normal macroscopically, but tuberculous changes were found micro- 
scopically, and bacilli were demonstrated in the blood from the um- 
bilical vein. Apparently the mother infected the fetus shortly Before 

1 Ziegler's Beitr., ix, 428; Miinchen. med. Wchnschr., 1904, p. 1676. 

2 Ibid., 1891, ix, 428. 



HEREDITY 91 

death. Londe 1 was the first to investigate the offspring of tuberculous 
mothers by inoculation tests, and he obtained positive results in some 
cases — guinea-pigs were infected when inoculated with the placental 
tissue, the fetal blood, and other organs. The most virulent tissue was 
found in the placenta. Warthin and Cowie 2 reported several cases in 
this country, but even they warn that " intra-uterine transmission of 
tuberculosis is possible, but extremely rare, and needs to be supported 
by further research before it can be taken as final." Martha Woll- 
stein 3 described a case in which the mother died six days after confine- 
ment, and the child died nineteen days after birth. The placenta 
showed advanced tuberculous changes, and the infant showed miliary 
tuberculosis of the lungs, spleen, kidneys, and mesentery. It is, 
however, noteworthy that tuberculosis of the placenta, which is more 
common, may not affect the fetus. Thus, A. S. Warthin 4 and Carl 
Vernon Weller 5 have reported cases of placental tuberculosis, and still 
the infants thrived for months after delivery. 6 

Another point is that it is rare that tuberculous changes should be 
found macroscopically in newborn tuberculous infants in which tubercle 
bacilli are demonstrated microscopically and by inoculation tests. 
This form of congenital tuberculosis has been named by Honl Status 
bacillaris with a view of distinguishing it from true congenital tubercu- 
losis with structural changes of a tuberculous nature; in the former, 
no macroscopic nor microscopic changes are found; while in the latter 
they are found, though both are capable of infecting when the tissues 
are injected into animals. 

Of the cases which have been reported as congenital tuberculosis, 
very few are accepted as such by careful critics. In most it has been 
shown the evidence is against their being really cases in which intra- 
uterine infection took place. Thus Pehu and Chalier 7 found only 51 
authentic cases on record in medical literature. It may be added that 
most of the cases were not conclusively proved. R6mer s knows of 
but 30 cases and some of them may be said to be reliable only "in 
all probabilities." Pehu and Chalier believe that in these cases infec- 
tion usually takes place at the end of pregnancy when the placental 
circulation is established and results from a bacteriemia which is usually 
a terminal event. They should therefore be regarded as examples of 
transplacental heredocontagion and not of direct heredity. 

It is thus shown that, theoretically, placental transmission of tuber- 
culosis is possible. But all available facts combine to prove 'that it 
is exceedingly rare among human beings. Indeed, when compared 

1 Rev. de la tuberculose, 1893, i, 125. 

2 Jour. Infect. Dis., 1904, i, 140; Ibid., iv, 347. 

3 Arch. Pediat., 1905, xxii, 321. 4 Jour. Am. Med. Assn., 1913, lxi, 1951. 

5 Arch. Intern. Med., 1916, xvii, 509. 

6 A complete review of the literature of congenital tuberculosis may be found in F. 
Parkes-Weber's paper recently published in the British Jour. Children's Dis., 1916, 
xiii, pp. 321 and 359. 

7 Arch, de med. des enfants, 1914, xvii, 721. 8 Loc. cit., p. 276. 



92 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

with the large number of infections after birth, the few recorded cases 
of congenital tuberculosis sink into insignificance. After all, when it 
does occur at all, it is from mothers who are in the far-advanced 
stages of phthisis, or who have tuberculous disease of the genito- 
urinary system. Such women only rarely conceive, and when they 
do, abortion is the rule. It is a fact worthy of note in this connec- 
tion that numerous examinations of stillborn fetuses from phthisical 
mothers have not revealed any traces of tuberculous infection; even 
inoculation experiments have failed in most cases. 

Among cattle congenital tuberculosis appears to be more frequent 
than among humans. Still, the application of the well-known Bang 
system has shown that, even here, it is exceedingly rare. In the United 
States Harlow Brooks 1 has shown that when calves are removed from 
their tuberculous mothers immediately after birth, they do not develop 
the disease. 

Clinical Facts of Heredity. — Many authors have observed certain 
clinical phenomena which cannot be explained otherwise than by 
heredity, either of the disease or of a predisposition to it. Brehmer, 
and after him several other writers, found that in many cases the 
onset of the disease occurs at the same age in parents and children. 
Piery found that in many families the children mostly succumb before 
attaining the age of sixteen. While many cases can be cited in sub- 
stantiation of these observations, it appears that so far a sufficient 
number have not been collated to prove their significance conclusively. 

Of greater moment is the inheritance of the locus minoris resistentioe, 
which Brehmer described long ago and Turban, 2 Baldwin, 3 Moeller, 
Kuthy, 4 and others have confirmed it. It appears that when pulmonary 
tuberculosis occurs in parents and children, the chances are immense 
that the same side of the chest should be affected in each case. This 
family resemblance in phthisis has been found in about 75 per cent, of 
cases. In my own experience I also observed that in about two-thirds 
of cases the side affected was the same in the several affected members 
of the family. Moeller 5 points out that when a child suffers from a 
tuberculous lesion of some bone, the chances are that when its brother 
or sister develops tuberculosis it will also be a disease of bone and 
not of the soft tissues. These facts are explained by the assumption 
that some organs or tissues in the body lack powers of resistance, and 
that this defect is transmitted by heredity. This will be discussed 
again when speaking of the thoracic anomalies and their relation to 
phthisiogenesis. Meanwhile it may be stated that these problems 
have not received the careful study they deserve. 

Disturbances in the Metabolism as Predisposing Factors.— In the 
search for the factors predisposing to phthisis many have looked into 

1 Am. Jour. Med. Sc., 1914, cxlviii, 718; Tr. Soc. Expei. Med. and Biol., 1914, xi, 50. 

2 Ztschr. f. Tuberk., 1900, i, 30. 3 Ya le Med. Jour., 1902, p. 215. 

4 Ztschr. f. Tuberk., 1913, xx, 38. 

5 Lehrbuch d: Lungentuberkulose, Berlin, 1910, p. 30. 



METABOLIC DISTURBANCES 93 

the metabolism of the body, stating that tuberculous infection is 
harmless in the vast majority of persons, so long as the metabolic 
processes are normal; only when certain disturbances occur in this 
regard can phthisis develop. Some excellent investigations into the 
functions of the internal secretion of the ductless glands have brought 
no positive results so far. At any rate, we do not know at present that 
disturbances in the structure or functions of the thyroid, pituitary, or 
suprarenal glands have an influence in enhancing the growth of tubercle 
bacilli in the body. The amenorrhea occurring in many tuberculous 
women is one of the results of the disease, and not a cause of it. It is, 
however, a fact that in the enormous literature on the subject of tuber- 
culosis, we cannot find an exhaustive study of the metabolism of persons 
affected with the disease, and hardly anything about the metabolism 
in the so-called pretuberculous stage. 

Several authors have maintained that an excessive excretion of cal- 
cium in the urine can be found in all cases of phthisis long before the 
onset of the disease. In this country Croftan, 1 John F. Russell, and, 
more recently, John O. Halverson, Henry K. Mohler and Olaf Ber- 
geim 2 have made some studies along these lines. The last-named in- 
vestigators have found that the calcium content of the blood of patients 
with advancing and convalescing tuberculosis revealed that in incipi- 
ent cases in which the patients, who were on a high milk diet, showed 
marked improvement, the values for calcium in the serum were normal 
and fairly constant. In advanced cases the variations obtained were 
greater (some rather high and some rather low values being obtained) , 
and improving patients showed on the average slightly higher values 
than the unimproved. No marked deviations from the normal, how- 
ever, were observed in the calcium content of the serum of patients 
in various stages of pulmonary tuberculosis. It is the opinion of these 
investigators that the failure of the body to deposit lime around the 
tuberculous areas is to be ascribed not to a deficiency in blood calcium, 
but rather to an inability of the cells of the tuberculous area to utilize 
available calcium. 

Several French savants, notably Robin, Binet, etc., have found that 
in the pretuberculous stage there is a pronounced excess in the excre- 
tion of inorganic salts in the urine, notably those of lime and magnesia. 
The result is that the blood, bones, and lung tissues show a distinct 
lack in these mineral salts. Gaube found that the descendants of 
phthisical subjects excrete on the average more calcium and magnesia 
than those of healthy stock. Robin sees in this lime and magnesia 
starvation an excessive amount of self-combustion, and he considers 
this anomaly in the metabolism the main element in the preparation 
of the soil prone to tuberculosis, whatever the remote cause may be — 
heredity, alcoholism, malnutrition, overwork, etc. Infection alone is 
insufficient to produce phthisis, as is evident from the fact that most 

1 Sixth Intern. Cong. Tuber c, 1908, i, 275. 

2 Jour. Am. Med. Assn., 1917, lxviii, 1309. 



94 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

people infected with tubercle bacilli escape the disease. It is only 
when the soil is prepared by the dissimilation and emaciation, by 
pretuberculous decay, as Robin calls it, that phthisis may develop. 
The gravity of the pulmonary lesion goes hand-in-hand with the 
degree of lime starvation, demineralization and emaciation of the body. 
According to these writers, phthisis is preventable. Demineralization 
of the body must be sought and, when discovered, prevented by the 
administration of remedies tending to replace the lime and magnesium 
which are being eliminated from the body excessively. 

These and other findings about the metabolism in phthisis have 
not been confirmed by all w T ho have made careful studies along these 
lines. It appears that in the vast majority of consumptives the metabo- 
lism is quite normal so long as there is no high fever. The occasional 
lapses in the metabolism are explained by the usual causes of morbid 
phenomena observed in other diseases characterized by fever, emacia- 
tion, debility, etc. At any rate, this subject has not been studied 
sufficiently to permit making generalizations. 

Anatomical Peculiarities Predisposing to Phthisis. — The hereditary 
and constitutional factors discussed above may explain some of the 
phenomena of tuberculous disease, but they fail to give an adequate 
explanation for all the cases of phthisis which are met with in practice. 
For these reasons many authors have suggested that local and anatom- 
ical peculiarities are responsible for the liability of the lung apex to 
tuberculous degeneration. 

Various hypotheses have been promulgated with a view of explain- 
ing why phthisis is localized in nearly all cases in adults in the apices 
of the lungs. Some have suggested that the determining factor is 
the blood content of these organs. It is shown that in congenital 
heart disease, pulmonary stenosis, which is characterized by oligemia 
of the lungs, nearly all patients succumb to pulmonary tuberculosis. 
On the other hand, in diseases of the left heart, especially in mitral 
stenosis, which are characterized by hyperemia of the lungs, phthisis 
is very rare. It has also been found that in the upper parts of the 
lungs the blood and lymph currents are slower than in other parts, 
and thus embolic deposits of bacilli are favored, no matter by which 
channel they have entered. Calmette's experimental investigations 
(see p. 50) seem to confirm this view. Then it must be mentioned 
that the uppermost three ribs show lesser respiratory excursions than 
the lower ribs. The result is a slower air current in the upper part of the 
lung and secretions and foreign bodies brought in by the inspired air 
are retained in the apex. But these, and many other hypotheses, have 
failed to adequately explain the apical localization of phthisis, especially 
now, since we know that infection takes place during childhood, while 
the evolution of the disease begins after maturity of the patient, as a 
rule. 

Physical Stigmata in the Tuberculous. — In the search for physical 
.stigmata in the tuberculous, various authors have found certain pecu- 



ANATOMICAL FACTORS 95 

liarities in some few phthisical individuals and thus tried to prove 
that these characteristics are either predisposing to the disease or 
are the result of anatomical changes wrought by the tubercle bacilli. 
Thus it has been stated that individual variations in the lymphatic 
system render infection and subsequent development of the disease 
easier, according to Cornet, 1 and also to Virchow, and others. Most 2 
is satisfied that deficiency of the valves of the lymphatic system would 
greatly widen the possible channels of tuberculous invasion, and spread 
through the body. Geddes 3 argues that the dilated veins found on 
the chest of some consumptives are pretuberculous, a stigma of an 
internal anomaly which predisposes to tuberculosis. He shows that 
the enlarged veins across the sternum are the external marks of a devel- 
opmental insufficiency of the pulmonary veins which cause increased 
pressure in the pulmonary arteries and hypertrophy of the right heart; 
the consequent increase in the size of the pulmonary arteries interferes 
with the proper lymph return. An area of sluggish drainage is to be 
considered a suitable soil for the growth and proliferation of tubercle 
bacilli. 

Even "stigmata of degeneration," in the sense given this expression 
by Lombroso, are alleged to have been observed to a preponderating 
degree in phthisical subjects by some authors. Thus, Charles J. 
Holeman 4 says that he observed stigmata of degeneration very fre- 
quently among tuberculous, "the most common, as well as the most 
striking and easily observed, are the various malformations of the 
pinna; next to these, ill formed palates and gross facial asymmetries 
abound." Among 233 cases he noted such stigmata in 188, or 80 per 
cent. Rossolimo 5 described the absence of the lobule — the so-called 
" jug-handle ear" — as very common in the tuberculous. Several 
authors agree with him, but I have not been able to convince myself 
of the truth of this assertion by observation of a large number of 
cases. Iwai, 6 a Japanese author, found polymastia and supernumerary 
nipples very frequent among tuberculous individuals. W. C. Rivers 7 
has written a complete book to prove that certain atavistic tendencies 
are found in most consumptives, notably ichthyosis, squint, etc. 

Fremiti's Theory of Stenosis of the Upper Thoracic Aperture — 
About sixty years ago Freund 8 pointed out that stenosis of the bony 
thorax is very frequently encountered in consumptives, but his obser- 
vations were neglected and soon forgotten, to be taken up again by 
himself, Hart and Harras, 9 and others. Bacmeister's 10 experimental 
investigations have finally given great plausibility to Freund's theory. 

1 Scrofulosis, London, 1914, p. 73. 

2 Archiv f. Anatomie u. Entwickelungsgeschichte, 1908, p. 1. 

3 Dublin Jour. Med. Sc, 1909, cxxviii, 337. 4 Med. Record, 1915, lxxxviii, 1037. 
s Wien. klin. Wchnschr., 1908, xxi, 790. 6 Lancet, 1907, ii, 958. 

7 Three Clinical Studies in Tuberculous Predisposition, London, 1917. 

8 Beitr. z. Histologie d. Rippenknorpel, Breslau, 1858. 

9 Der Thorax phthisicus, Stuttgart, 1908. 

10 Die Entstehung der menschjichen Lungenphthise, Berlin, 1914. 



9G 



FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 



The deformity of the upper thoracic girdle, which may be congenital 
or acquired, consists mainly in an ossification of the first costal cartilage 
and a shortening of the first rib which exerts pressure upon the lung 
apex which it surrounds, thus obstructing the circulation of the blood 





Fig. 5. — Diagrammatic representation of the upper aperture of the thorax: a, the 
primary form (animals, primitive human form); b, secondary form (adult man). (After 

Wiedersheim.) 

and lymph and preventing the removal of any foreign body — the 
tubercle bacilli — that may be brought there by the blood or the 
inspired air, and favoring its localization at this point. Shortening of 
the first costal cartilage also involves an excessive inclination of the 
upper thoracic aperture toward the spinal column. The sternum lies 




Fig. 6. 



-Upper aperture of the thorax: A, normal on left side; B, narrowed at the 
right. (Freund.) 



too deeply, the ribs run slantingly downward, the shoulders hang low 
and forward, the scapulae protrude like wings, and the result is the 
phthisical chest'of the classical authors. 

Freund, Hart, and Harras have studied the tuberculous thorax 



ANATOMICAL FACTORS 



97 



on the autopsy table and in the living with the aid of radiography, 
and have found that stenosis of the upper aperture is very frequent. 
The abnormal shortening of the first rib makes the transverse diameter 
short, converting the human thorax into one like that of the lower 
animals, and to a certain extent infantile, as is shown in Fig. 5. The 
narrowing usually occurs at the lateroposterior bulging, exactly where 
the apices of the lung are surrounded by the first rib, which under 
these conditions compresses the pulmonary tissues beneath. This 
deformity may occur unilaterally or bilaterally, but the end-result 
is always the same — narrowing and rigidity of the upper thoracic 
girdle with resulting compression of the lung. 




Fig. 7. — 'Right lung. (His's model.) 
The indentations made by the ribs are 
shown. The first groove is the indentation 
made by the first lib and is known as 
Schmorl's groove. 



Fig. 8. — Left lung. The groove of the 
first rib is shallower than in the right 
lung. 



Independent of Freund, Schmorl 1 found a groove about 2 cm. below 
the highest point of the apex of the lung. This groove is very frequently 
encountered in newborn infants, but in them it can be obliterated when 
the lung is inflated. During adolescence it disappears in persons with 
normal chest walls. In most persons in whom it persisted Schmorl 
found tuberculous lesions beneath the point which was pressed upon 
by the shortened rib (Figs. 7 and 8). 



Mlinchen, med. Wchnschr., 1902, xlviii, 1995. 



98 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

These observations have been confirmed by Birch-Hirschfeld 1 from 
another point of view. While searching for the initial lesion of tuber- 
culosis in cadavers dead from other diseases, he found that phthisis 
begins in the walls of a bronchus of the third to the fifth order, and 
ascribed it to certain pressure exerted on these tubes, preventing the 
exit of air and secretions. This bronchiole, which Clifford Allbutt 
calls "Hirschfeld's bronchiole," from its position and nature, favors 
that secretions, instead of clearing themselves automatically, will 
stagnate more or less if pressed upon to a greater or lesser degree by 
the first rib, located as it is on the apex, leading spirally against the 
action of gravitation upward, outward, and backward. 

Finally, Bacmeister's 2 investigations have apparently confirmed 
these anatomical, pathological, and clinical findings. He surrounded 
young and growing rabbits with a wire loop at the first costal ring, 
thus causing stenosis of the upper aperture of the bony thorax. The 
pulmonary apex was thus compressed, and a groove was indented in 
the lung beneath the wire loop corresponding to the one observed by 
Schmorl in human consumptives. Infecting these animals, he pro- 
duced isolated and localized pulmonary tuberculosis, while in normal 
animals, used as controls, infection produced miliary tuberculosis, 
but never localized tuberculosis of an apex. In this manner he 
could produce local tuberculous lesions on either side of the chest, 
or bilaterally. 

There is considerable evidence in support of this theory. In children, 
the upper aperture of the thorax is very elastic, and therefore apical 
phthisis is exceedingly rare; when infected, the tracheobronchial glands 
are affected, or general miliary tuberculosis is the result. During 
the period of puberty, when the spinal column grows and raises the 
upper thoracic girdle, permitting the first rib to exert pressure on 
the pulmonary apex, typical phthisis may occur. The largest number 
of cases of active tuberculosis of the lung, though not the largest 
number of deaths due to this cause, occur between fifteen and thirty 
years; between thirty and forty the proportion diminishes, and be- 
tween forty and sixty there again occur a large number of cases. 
Hart explains these phenomena in this manner: During puberty and 
soon thereafter any congenital or acquired shortening of the first rib 
becomes dangerous to the individual because the growing apex of 
the lung finds itself enclosed in the small and rigid thoracic cavity, 
which does not grow in the same proportion as the lung, and the 
shortened first rib compresses it, thus favoring tuberculous degenera- 
tion. After forty, when ossification of the costal cartilage is, to a 
certain extent, normal, conditions are again favorable for the develop- 
ment of phthisis. 

While several authors have confirmed Freund's and Hart's findings, 
others, like Schulze and Smith, have looked for stenosis in the upper 

1 Deutsch. Arch. f. klin. Med., 1899, lxiv, 58. 

2 Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1913, xxvi, 630. 



DISEASES OF THE RESPIRATORY TRACT 99 

aperture of the thorax while making autopsies on tuberculous subjects, 
and could not find it in as large a proportion of cases as Freund and 
Hart reported. 

Arthur Keith, 1 Stiller, 2 and other authors are inclined to look upon 
this deformity of the thoracic girdle rather as a result of tuberculosis 
than a cause of it. Pottenger 3 points out that the muscle change 
described by Freund as hypertrophic and due to overwork, caused by 
the muscle pulling against an ankylosed rib, is more likely a contrac- 
tion of the muscle caused by the inflammation within the lung reflexly 
through the spinal cord. It is also probable, according to Pottenger, 
that the cause of the ossification of the cartilage and ankylosis of the 
costosternal and sternomanubrial articulations is also a reflex. "The 
contraction of the muscles covering the apex, together with the limited 
motion on the part of the diaphragm which is present in even small 
pulmonary lesions, together with the decreased expansibility and 
lessened elasticity of the parenchyma of the underlying lung, caused 
by the inflammatory process within, are causes of lessened motion 
at the apex; and that these conditions, together with the trophic 
changes which occur in the bone and cartilage as a result of the reflex 
stimulation of the nerves which supply these structures, favor anky- 
losis and ossification." 

Of course, the suggestion made by several authors that operative 
interference is indicated in cases with stenosis of the upper aperture 
of the thorax for the prevention or cure of phthisis, is rather premature. 
But it appears that among the many predisposing causes of this disease, 
the thoracic anomaly just described may play an important role. At 
any rate, it is worth while to continue investigations along these lines. 

Diseases of the Respiratory Tract as Predisposing Factors. — Of 
the diseases which have at one time or another been considered pre- 
disposing to phthisis, those affecting the respiratory tract are nearly 
always mentioned as preparing a favorable soil for the growth of 
tubercle bacilli. Thus, we occasionally meet with cases of bronchi- 
ectasis, syphilis, actinomycosis and cancer of the lungs and chronic 
pneumonia, in which tuberculosis is implanted at the site of the 
primary disease. There are two plausible explanations for these 
phenomena: In most cases it is, in all probability, an old, dormant 
tuberculous lesion, dating back to childhood, that is reawakened into 
activity by the new disease, assisted by the reduction in vitality and 
resisting power of the patient. In pneumokoniosis the non-tubercu- 
lous lesion in the lung produces a local ischemia, obstructs the lymph 
channels, and thus prevents absorption or destruction of any tubercle 
bacilli that may be brought in by the air stream. Pure lobar pneumonia 
is hardly ever followed by phthisis and, in most cases in which it jjf s 
said to have been observed, the probabilities are in favor tha^rthe 

1 Further Advances in Physiology, 1909. 

2 Berl. klin. Wchnschr., 1912, xlix, 97. 

3 Muscle Spasm and Degeneration, St, Louis, 1911, 



100 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

primary disease was acute pneumonic phthisis which had subsided 
and followed the course of chronic phthisis. Especially is this the 
case with apical pneumonia and basal phthisis and many of the so- 
called " unresolved pneumonias" have been tuberculous from the start. 

Pleurisy. — Of greater importance is the etiological relation of pleurisy 
to phthisis. Of course, the secondary pleurisies, those occurring in 
cases of thoracic neoplasms, cardiac and renal disease have no signifi- 
cance in this regard. But the forms of acute and chronic pleurisy 
which have been formerly considered "idiopathic," appear to be, 
in the vast majority of cases, of a tuberculous nature, though many 
are undoubtedly rheumatic. 

Strictly speaking, pleurisy cannot be considered as a predisposing 
cause of phthisis, because it appears that it is essentially tuberculous. 
As will be shown later on (see Chapter XXVI), it is practically estab- 
lished that most cases of "idiopathic" pleurisy are caused by tubercle 
bacilli. This means that it is not predisposing to phthisis, but that 
patients with pleurisy are actually tuberculous from the start. 

Diseases of the Upper Respiratory Passages. — We often meet with 
persons who have suffered for years from frequent "colds," showing 
inflammatory changes in the nose, rhinopharynx and pharynx, recur- 
rent bronchitis and tracheitis, and finally tuberculosis develops. Espe- 
cially in children with chronic nasal catarrh, hypertrophied tonsils, or 
adenoids, tuberculosis has been stated to be very frequent. The fact 
that these young subjects often have enlarged cervical glands has con- 
tributed to the assumption of their predisposition. As a manifestation 
of the traditional "scrofula" also these morbid phenomena have been 
considered as in themselves tuberculous. 

Because the tonsils are easily infected with tubercle, and also 
because a certain number of tonsils removed from patients have been 
found harboring tubercle bacilli, many authors have argued that the 
tonsil is one of the main channels of entry of tuberculous infection in 
man; especially tuberculous cervical adenitis has been attributed to 
tonsillar infection. Wood proved this to be the case experimentally 
in swine, and Ravenel 1 in monkeys. From a collection from the litera- 
ture of 1671 tonsils, Wood finds that 88, or 5.2 per cent., showed 
primary tuberculous lesions. Lartigau and Goodale have even found 
a higher percentage of positives by the inoculation tests. A. P. 
Mitchell, 2 examining the tonsils removed from 100 children and 6 
adults, with cervical adenitis, found that 41 showed undoubted tuber- 
culous lesions. He made inoculation tests in 92 of the 106 cases, and 
obtained positive results in 20, the bovine type of bacillus being found 
in 16, and the human type in 4 cases. Many authorities, notably 
Ravenel in this country, are of the opinion that the evidence that 
the faucial tonsil is frequently the portal of entry for the tubercle 
bacillus is very conclusive. Clinical experience is, however, not in 

1 Jour. Am. Med. Assn., 1916, lxvi, 613. 

2 Jour. Pathol, and Bacteriol., 1917, xxi, 248. 



EMPHYSEMA AND ASTHMA 101 

agreement with this view. If most of the children with hypertrophied 
tonsils would develop active tuberculosis, the number of tuberculous 
would be much higher than we observe. The enlarged glands seen in 
these children are not necessarily tuberculous and in the cases in which 
they are, the bovine type is responsible, and this form of tuberculosis 
is not at all dangerous, and it is problematical whether it has anything 
to do with phthisis in the adult. 

Pulmonary Emphysema and Asthma. — Of interest is the relation of 
emphysema of the lung and asthma to phthisis. Rokitansky said that 
pulmonary emphysema and tuberculosis occupy a relation of mutual 
exclusion; and Trousseau considered asthma and tuberculosis as an 
expression of the same diathesis. Asthmatic patients may bring forth 
tuberculous children, and conversely, tuberculous parents may have 
asthmatic children. Brugelmann says that the contrary is true — as 
long as one has asthma he is immune to tuberculosis, and S. West 1 is 
of the opinion that "phthisical patients very rarely suffer from spas- 
modic asthma, and if an asthmatic patient becomes phthisical, an event 
which is by no means common, the asthma usually disappears." 
This is in agreement with the view of F. A. Hoffmann, 2 who says 
that when the two diseases combine, each gives up a part of its pecu- 
liarities; the asthma, its characteristic paroxysmal character — the 
attack becomes weak and indistinct and passes over into indefinite 
dyspneic conditions; the tuberculosis, its progressive character — it is 
prolonged and degenerates into fibroid phthisis. The same author 
considers an emphysematous lung as a distinctly unfavorable soil for 
the development of tuberculosis. 

My own experience leads me to agree only partly with these views. 
True bronchial asthma is only rarely complicated by phthisis, in fact 
I have hardly seen half a dozen cases in which this has happened. 
The paroxysmal attacks of cough and dyspnea seen in some consump- 
tives have often been mistaken for asthma, but a careful consideration 
of the history and symptomatology of the case shows that they are but 
pseudo-asthmatic attacks, encountered almost exclusively in fibroid 
phthisis, and at times in cases of acute pneumonic phthisis. It is 
different with pulmonary emphysema. I have seen many cases of 
emphysema complicated by tuberculosis, particularly in workers at 
dusty trades, garment workers, furriers, rag-pickers, etc. It appears, 
however, that the tuberculosis pursues, as a rule, an exceedingly mild 
course and is very difficult of diagnosis, excepting by a microscopic 
examination of the sputum. 

In this connection it is well to bear in mind the difference in the 
ages at which these two diseases are most likely to occur: Phthisis is 
mostly a disease of adolescents and adults before thirty, while emphy- 
sema is mainly seen in persons over forty years of age. It is in the latter 

1 Diseases of the Organs of Respiration, London, 1909, p. 600. 

2 In Nothnagel's Practice, American edition, Diseases of the Bronchi, Lungs and 
Pleura, 1903, pp. 241, 291. 



102 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

class that tuberculosis often develops in an emphysematous lung. 
Emphysema is also frequently seen in chronic phthisis which has 
healed, and also in the unaffected lung or parts of the lung in patients 
with active phthisis. 

The reasons why asthma and emphysema are some protection 
against phthisis are not clear. Some are inclined to attribute it to 
the atrophic condition of the pulmonary parenchyma which renders 
it unfavorable for the growth of the bacilli; others believe that be- 
cause the inspiratory current is slow and inadequate, it cannot bring 
bacilli deeply into the lung. Perhaps the venous hyperemia, which is 
present in most cases of emphysema, prevents the development of 
phthisis as certain forms of heart disease do. 

Diseases of the Heart and Bloodvessels. — Diseases of the heart 
have also been found etiologically related to the development of 
phthisis. Louis, 1 in 1836, pointed out that the heart of the consumptive 
is small, and ever since considerable evidence has accumulated showing 
that the size, capacity, and thickness of the walls of this organ are 
usually smaller in the consumptive than in healthy persons. Many 
authors even consider a congenital hypoplasia of the cardiac muscle 
a prerequisite, or at least a predisposing factor, in phthisis. That an 
hypertrophied heart is exceedingly rare in phthisis is well known to 
all who have examined chests with the aid of radioscopy, or made 
autopsies on persons who died from tuberculosis. C. Guarini, 2 report- 
ing Roentgen findings in 1300 consumptives, points out that even in 
suspects the heart is very frequently small, and located in the median 
line of the body, instead of slanting to the left; the "drop" heart he 
found in 13 per cent, of cases, while the arch of the aorta is relatively 
small. Skiagraphy of persons with small and vertical heart always 
reveals tuberculous lesions in the lungs. Altogether he found that in 
68 per cent, of the 1300 tuberculous patients the heart was small and 
vertical. 

Careful pathological research has, however, shown that in the incip- 
ient stage the heart is of normal size and that with the progress of the 
disease it participates in the wasting process of the organs of the body, 
especially the muscles. In other words, the small heart is an expres- 
sion of the general cachexia of phthisis, a phenomenon often observed 
in other wasting diseases, notably cancer. But even this is denied by 
some competent observers. Sir Douglas Powell 3 says: "I have always 
held the belief that the heart in pulmonary tuberculosis did not par- 
take in the wasting of other muscles, and although perhaps not abso- 
lutely of normal weight, was yet relatively, or perhaps more than 
relatively so, in relation to the body weight. My expression clinically,- 
too, is that the right side of the heart is relatively somewhat enlarged 
and thickened in the chronic forms of the disease." 

1 Recherches anatomico-pathologiques sur la phtisie, Paris, 1825. 
- Riforma med., 1918, xxxiv, 485. 
3 Lancet, 1912, ii, 1415. 



DISEASES OF THE HEART AND BLOODVESSELS 103 

On the whole, it can be stated that a small heart is not a predisposing 
factor in phthisis, as has been assumed by some authors. Even the 
suggestion that a small heart may cause relative anemia of the lungs 
does not hold, as a rule, because, while it is true that with each beat a 
lesser amount of blood is propelled to the lungs, this, however, is com- 
pensated by the greater frequency of the heart beat. 

But a large and hypertrophied heart appears to a certain extent a 
protection against the development of phthisis. This is seen in the 
case of valvular disease, especially of the left side of the heart. As far 
back as 1844 Rokitansky 1 asserted that diseases of the heart and blood- 
vessels producing passive congestion of the lungs are a preventive 
of phthisis. Traube later modified this law by saying that only 
mitral stenosis excludes phthisis, while in aortic disease tuberculosis is 
occasionally met with. Fagge also held that mitral stenosis is almost a 
complete bar to tuberculosis, the postmortem records of Guy's Hospital 
supplying only 4 cases in the course of thirty years. Percy Kidd's 2 
statistics give only 1 instance in 500 cases, and Walsham's, 1 in 130 
cases. 

Inasmuch as this point has lately been contested in this country 
by Norris, Burns, and others, it is worth while to find out what autopsies 
made in recent times have revealed. Among 4359 autopsies performed 
by Birch-Hirschfeld, he found that 907, or 20.8 per cent., presented 
lesions of chronic pulmonary tuberculosis; among 107 with valvular 
lesions, only 5, or 4.6 per cent., showed tuberculous lesions in the lungs, 
and of these the heart defect was in the pulmonary valve in 2. In 
other words, only 3 cases of mitral disease with tuberculosis were 
found in this large material. Norris 3 collected from the literature 
records covering 8154 autopsies on tuberculous subjects where only 
3.5 per cent, showed signs of valvular heart disease. While personally 
performing 1764 autopsies on tuberculous subjects he found 130, 
or 7.3 per cent., of valvular disease. Anders 4 calculated only 1.2 per 
cent, in 10,687 autopsies, and Brown 5 collected figures of 71,115 
autopsies with but 0.9 per cent, of valvular heart disease in phthisis. 
Statistics like these show more conclusively than clinical observations 
the rarity of phthisis with mitral defects. Endocarditis may occur 
in the course of phthisis, as a complication, but in the majority of 
cases it appears after the onset of tuberculosis; it only rarely precedes 
it. As a terminal affection it is not rare, and then is usually due to 
staphylococci, streptococci and is, as a rule, verrucose in type. Tuber- 
culous endocarditis does occur, but it is exceedingly rare. 

Murmurs in phthisical subjects do not mean endocarditis, as a rule. 
They are usually due to fatty degeneration of the heart with dilatation, 
pleuropericardial adhesions, cardiac displacement, etc. The latter 

1 Handbuch der patholog. Anatomie, Vienna, 1844, ii, 520. 

2 St. Bartholomew's Hosp. Rep., xxiii, 239. 

3 Am. Jour. Med. Sc, 1904, cxxviii, 649. 

4 Ibid., 1909, cxxiii, 93. 6 Ibid., cxxxvii, 186. 



104 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

may even produce arrhythmia. C. M. Montgomery 1 found murmurs 
in three-fourths of all advanced cases of phthisis, although in his 171 
cases of pulmonary tuberculosis a positive diagnosis of endocarditis 
was made only in 2. Similarly, N. B. Burns's 2 cases were diagnosed 
merely by the murmurs which were audible over the cardiac region, 
and he says that most of them were complications of phthisis. 

In my own experience, I have' seen but 5 or 6 cases of true mitral 
stenosis developing phthisis. To be sure, I have met with presystolic 
murmurs at the apex, but these murmurs, as well as the decompensa- 
tion, appeared long after the onset of phthisis, mostly as a terminal 
phenomenon. I have repeatedly heard murmurs in a phthisical patient 
and when the case came to autopsy no valvular defect was found. 

It seems that mitral stenosis causes a mechanical impediment to 
the lesser circulation, thus creating congestion or plethora of the blood- 
vessels in the lungs, and this has been offered as an explanation for the 
antagonism between this disease and phthisis. But it must be borne 
in mind that in compensated mitral stenosis the lungs do not have 
a larger quantity of blood than normally; it is only with the onset of 
decompensation that the pressure is elevated and the blood stream 
is slowed, thus favoring a larger quantity of blood in the lungs. 

Those who accept the hematogenous origin of phthisis explain that 
in this manner the smaller vessels are dilated and the opportunity 
for development of emboli of tubercle bacilli is reduced to a minimum. 
In mitral stenosis the congestion of the pulmonary vessels is greater 
than in insufficiency, and for this reason phthisis is more rarely encoun- 
tered in the former than in the latter. 

In congenital heart disease, pulmonary stenosis appears to predis- 
pose to phthisis and those who survive infancy and childhood with 
such heart lesions, succumb during adolescence to tuberculosis because 
of the defective circulation of blood and lymph in the lungs which this 
cardiac defect brings about. 

Diabetes. — For a long time diabetes has been considered as favor- 
ing the evolution of phthisis. It has been stated that the two diseases 
are very frequently associated and that phthisis in diabetics pursues 
a peculiar course, ending fatally in a short time. That glycosuria 
predisposes to tuberculosis has also been inferred from the fact that in 
animals the same condition has been observed. Thus, Schindelka 
reported pulmonary tuberculosis in a diabetic dog, and canines are 
usually very refractory to tuberculosis. 

The first to collect statistics on the subject was Griesinger who, 
in 1859, reported 250 cases of diabetes in whom he found 42 per cent, 
affected with tuberculosis. Windle even found that 50 per cent, of 
327 diabetics died from tuberculosis. But a more recent and thorough 
survey of the evidence by Charles M. Montgomery 3 shows that there 
is no conclusive proof that tuberculosis occurs more frequently in 

1 Am. Jour. Med. Sc, 1910, cxxxix, 870. 

2 Ibid., 1914, cxlvii, 866. 3 ibid., 1912, cxliv, 543. 



ACUTE INFECTIOUS DISEASES 105 

diabetics than in the general population at the same age periods. 
He found that out of 355 autopsies collected from the literature since 
1882,- including his own 25 cases, 138, or 38.9 per cent., revealed pul- 
monary tuberculosis, mostly in an acute form. This cannot be said to 
be very excessive if we consider the frequency of tuberculosis in the 
general population at the ages between twenty and fifty. 

It appears that diabetes hardly ever occurs in phthisical subjects. 
Whenever the two diseases are found in the same subject, the former 
was invariably the first disease. West, Raw, Montgomery, and others 
agree with this view. In my own experience, dealing with several 
thousand consumptives derived from a class (Jews) peculiarly predis- 
posed to diabetes, I have never seen one developing glycosuria while 
suffering from active phthisis. The reasons for this peculiarity are 
obscure. 

While in most cases tuberculosis occurring in diabetics runs a 
rapidly fatal course, which could be expected a priori considering that 
both are wasting diseases, I have seen many who lived on for many 
years. As Montgomery says, "Often each disease runs a course appar- 
ently independent of the other." We often see patients improving as 
regards their glycosuria or the pulmonary condition, or even both. 
I have a patient who has been diabetic and tuberculous for twelve 
years doing very well, excepting for occasional acute exacerbations of 
either condition. 

Acute Infectious Diseases. — It has repeatedly been observed that 
the endemic contagious diseases, like measles, scarlet fever, whooping- 
cough, diphtheria, etc., are often followed by phthisis, and in infants 
and children tuberculous bronchopneumonia is frequently a sequel of 
measles and whooping-cough. This heightened predisposition may 
be explained as depending on the general disturbance in health caused 
by the fever, catarrh of the respiratory passages, etc., which reduce 
the resisting power and produce a soil favorable for the activation of 
dormant foci of tubercle bacilli, or favor new infections. These diseases 
are accompanied to a great extent by irritation of the mucous mem- 
branes and defects in the epithelium which facilitate the entrance of 
the bacilli, so that infection of the respiratory passages is particularly 
favored. The influence of measles and whooping-cough may be purely 
mechanical; fits of violent cough are liable to rupture tuberculous 
glands in the chest. 

In children tuberculous bronchopneumonia is very frequently ob- 
served to follow an attack of measles. In adults our experience had 
been limited till the epidemic which broke out in various camps in which 
United States soldiers were stationed during 1917-18. Among 5945 
cases of measles in soldiers it was found that 173, or 2.91 per cent., 
had developed active tuberculosis. George E. Bushnell 1 is inclined to 
the opinion that the measles reactivated latent tuberculous foci, 

1 Jour. Am. Med. Assn., 1918, lxx, 1823. 



106 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

though he believes that it is probable that the number of really tuber- 
culous cases was less than the above figures would indicate. Some of 
these cases classed as tuberculous are rather cases of unresolveo^pneu- 
monia. But, on the other hand, he has no doubt that all cases of tuber- 
culosis reactivated by measles had been detected at the first examination 
of these soldiers. This may be considered an experiment on a large 
scale which tends to show the influence of measles on the incidence of 
tuberculosis. 

That these diseases may be strong predisposing factors to tubercu- 
lous infection and the extension of existing tuberculous disease, was 
shown from another viewpoint. "Allergy," or the altered reactivity 
of the organism to tuberculin, which is apparently dependent upon 
the fact that the body has produced antibodies which counteract the 
effects of tuberculous toxemia, is diminished in intensity, or disappears 
altogether, during an attack of measles. This "anergy" would indicate 
that resistance to infection has diminished, just as in far-advanced 
phthisis for a short period before the fatal termination, in miliary 
tuberculosis, etc., when all defensive powers have failed. Von Pirquet 
has named this state "anergic," i. e., non-reacting. He assumes that 
the measles process occupies the antibodies which are needed for the 
repulsion of the tubercle bacilli present in the body. During this 
unprotected period the tubercle bacilli can grow and pass through the 
necrotic walls of a caseous gland, or secondary diseases can also occur, 
because now the circulating tubercle bacilli can find favorable condi- 
tions where at other times they would have been destroyed. He draws 
an analogy between this condition and the condition favoring the prog- 
ress of tuberculosis in the adult — general debility due to malnutrition, 
overwork, or any other condition robbing the body of its natural 
defences. 

Influenza. — The connection between influenza and phthisis is even 
less clear. During the great pandemic of influenza in 1891 it was 
observed that the mortality was increased, and similar observations 
had been made before. Arthur Ransome 1 called attention to the 
periodic waves in the death-rate from phthisis in England and Wales, 
and noted faint indications of a rise in 1853, 1866, 1878 and 1890. 
Bulstrode, in referring to these rises in the mortality, pointed out that 
there was an outbreak of influenza in 1855 which might possibly account 
for the increase in tuberculosis at that time. But in 1866 the cotton 
famine accounts for it much better. During 1890-91-92, and again 
in 1899-1900, the mortality from phthisis increased as a concomitant 
to epidemics of influenza. As Newsholme 2 points out, the experience 
of 1915-16 was the third occurrence in recent years of this coincidence, 
and there can be no doubt that influenza is a most dangerous complica- 
tion of pulmonary tuberculosis. During the epidemic of influenza in 
the United States in 1918, 1 observed that those who recovered showed 

1 Tr. Epidemiol. Soc, London, xxiv, p. 252. 

2 Lancet, 1917, ii, 591. 



OCCUPATION 107 

no tendency to develop phthisis, unless they had tuberculous lesions 
before the attack of influenza. When a tuberculous person is stricken 
with influenza, the outlook is not invariably bad. 

Carefully studying the conditions, it appears that it was only the 
mortality from phthisis that was increased, and not the morbidity. 
Moreover, even this has not been lasting, for the mortality has been 
steadily declining despite the fact that influenza has been endemic 
all over the civilized world during the past thirty years. Clinically, 
we find that when a consumptive is subjected to an attack of influenza, 
the process in the lung is liable to extend, and acute exacerbation of the 
process is likely to occur which either kills the patient, or turns a 
chronic, and comparatively innocuous, process into a subacute one, 
and finally to a fatal termination. We see this in hospital wards during 
epidemics of influenza; the mortality rises. 

Typhoid Fever. — Typhoid fever also has been considered as predis- 
posing to phthisis because of the rather high proportion of consumptives 
who give a history of having passed through an attack of it. Recently, 
Charles E. Woodruff 1 has discussed the subject in great detail and 
arrived at the conclusion that typhoid fever heads the list of predis- 
posing causes of tuberculosis. The fact that during recent years the 
mortality from tuberculosis and from typhoid has been declining at 
almost the same rate is considered a strong argument. "The three 
diseases which seem to be most frequently followed by tuberculosis 
of the lungs — measles, whooping-cough, and typhoid — are all compli- 
cated with bronchitis." 

There appears to be a lack of evidence in support of these conten- 
tions. The fact that the mortality-rates from typhoid and phthisis 
run parallel does not prove that the same cause is operative in both 
cases. The somewhat excessive number of consumptives who have 
a history of typhoid does not convince in this direction. It is well 
known to clinicians that acute tuberculosis very often simulates typhoid 
in a striking manner, and with all our diagnostic methods it is often 
very difficult to differentiate the two diseases. In many cases of alleged 
typhoid preceding phthisis I have been convinced that it was an acute 
exacerbation of latent tuberculosis which was mistaken for typhoid, 
just as. many attacks of "grippe" are in reality acute exacerbations of 
chronic or mild forms of phthisis. Typhoid fever, like most other 
febrile diseases, may, however, activate latent phthisis, which might 
not have taken an acute or subacute course otherwise. But under the 
circumstances we cannot consider typhoid per se as predisposing to 
tuberculosis. 

OCCUPATION. 

Of the factors which have been mentioned as predisposing to the 
development and evolution of phthisis, the character of the occupa- 
tion of the patient has been given prominence by nearly every writer 

i Am. Med., N. S., 1914, xi, 17. 



108 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

on the subject. Very few, however, have looked at this problem with 
the view of William Gilman Thompson, who justly says that "it is 
often not the occupation which is at fault, but the manner in which 
it is conducted." It is also to be borne in mind that when we find that 
a larger number of persons in a certain trade or occupation are affected 
with phthisis, it does not necessarily follow that the occupation is 
responsible. As has been pointed out by Cobbett, hotel servants in 
England show a very high tuberculosis mortality. Some would be 
inclined to attribute it to their indoor life, as well as to their proclivity 
to drink excessively. But this would not account for it altogether. 
Others working indoors, as tailors, have not an excessive mortality. 
No doubt that there is a process of natural selection going on. The 
occupations which do not require excessive muscular work are likely 
to attract the weakly, and the sick, those who have latent tuberculosis. 
For this reason also policemen are less liable to develop phthisis — only 
strong men are taken into the service. 

Dust as an Etiological Factor in the Evolution of Phthisis.— Long 
ago Ramazzini spoke of the etiological relations of dust to diseases 
of the respiratory tract and at present, after we have studied the 
etiology of tuberculosis on a scientific basis, we find that the ancient 
clinician's observations have been confirmed in the main. In nearly 
all treatises on tuberculosis, or on occupational diseases, it is never 
omitted to state emphatically that persons pursuing occupations at 
which they are exposed to the inhalation of mineral, metallic, vege- 
table, or animal dust are more likely to contract tuberculosis, and die 
from it, than others. According to data obtained by the Twelfth 
Census of the United States, the death-rate from phthisis was 5.41 
per thousand among marble- and stone-cutters, as against only 1.12 
among farmers and planters, and 1.07 among lumbermen and 
raftsmen. Statistics published by the United States Bureau of 
Labor in 1908-1909 show that the mortality from tuberculosis 
among males from twenty-five to thirty-four years of age con- 
stituted 31 per cent, of the total mortality in the working population. 
But among grinders it was 71 per cent.; among tool-makers, 59 per 
cent.; printers, 56 per cent.; stone-cutters and weavers, 55 per cent.; 
spinners, 50 per cent.; woolen-workers, 44 per cent. Similar statistics 
are available for many other countries, and for other occupations in 
which the workers are exposed to the inhalation of mineral and metallic 
dust, especially grinders, tool- and instrument-makers, printers, etc. 
From a report of the Bureau of Labor in New York, it appears that 
the trades that showed the least effects from the ravages of consump- 
tion were the boot- and shoemakers, and millers. 

It would seem that, with the exceptions to be mentioned later, 
mineral dust is the most dangerous in this regard, as has been shown 
by W. Zeuner, 1 Harlow Brooks, 2 Frederick Hoffman, 3 and others. 

1 Luftreinheit zur Bekampfung der Tuberkulose, Berlin, 1903. 

2 Dietetic and Hygienic Gazette, 1907, xxiii, 709. 

3 Bulletin of Bureau of Labor, November, 1908, p. 633. 



OCCUPA TION 109 

Undoubtedly, it is the jagged and sharp-pointed particles which act 
as an irritant to the pulmonary tissues. Nature has placed many 
barriers in the way of even fine dust entering into the deep respiratory 
passages with the inspired air; even when reaching the mucous mem- 
brane of the bronchi and lung, the latter are very tolerant and most 
of it is soon expelled with the expectoration. But Moritz found that 
the sensibility of the respiratory tract, from the nose to the trachea, is 
reduced in persons working as grinders in a steel factory in Germany. 
Large masses of metallic dust could be seen lying on the vocal cords 
and mucous membrane of the trachea without provoking cough. For 
this reason some dust often remains and is taken up by the lymph 
channels and carried away. But after persistent deposits of dust in 
the alveoli, the irritation it produces excites a reactive inflammation, 
clogs up the lymph channels and lowers the resisting powers of the 
invaded lung, preparing the soil for the deposit of tubercle bacilli 
which may thrive in such defective areas di lung tissue. The glands 
of the lungs act as filters which retain the dust brought in by inhalation. 
But if new deposits of dust are brought repeatedly into these glands 
they are ultimately doomed to become damaged and their function as 
filters impaired, or even abolished. They are supersaturated with dust 
and, like a sponge which is supersaturated, can absorb no more. 
Zeuner is of the opinion that the glands of the deeper respiratory 
passages produce an internal secretion which is bactericidal, destroy- 
ing any microorganism that may enter with the inspired air, including 
tubercle bacilli; at all events, it prevents their growth. Dust destroys 
the structure and function of these glands. 

It appears that phthisis in patients with pneumokoniosis is often of 
a special form, pursuing a slow, sluggish course and with a symptoma- 
tology peculiarly its own. Fibroid phthisis, which will be discussed 
later on, is mostly found in workers exposed to the inhalation of animal 
or vegetable dust. The foreign particles deposited in the alveoli excite 
a productive inflammation. At first, small diseased foci are pro- 
duced, but later, if the irritation keeps up, the small foci coalesce, 
affecting extensive areas of pulmonary tissue, and tubercle bacilli, 
either brought by the inspired air or by metastatic deposits from old, 
latent lesions, invade these areas secondarily. 

This form of phthisis may last for years without greatly incapaci- 
tating the patient, who may have no fever, no debility, no nightsweats, 
etc. ; only cough and expectoration, and very often dyspnea, being the 
annoying features clinically. I have observed this form of phthisis 
among garment- workers, notably furriers, in New York City. 

But not all dust is etiologically related to phthisis. Thus, among coal- 
miners, who undoubtedly inhale large quantities of mineral dust, which 
almost invariably reaches the deeper respiratory passages and remains 
there as is evident from the frequency of pneumokoniosis among them, 
true tuberculous phthisis is comparatively infrequent. Kuban drew 
attention to this fact as far back as 1863 in France where "coal dust 



110 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

is unable to cause pulmonary tuberculosis or even favor the evolution 
of pulmonary tubercle. It prevents the development of phthisis." 
In his book on occupational diseases, Oliver shows that this is true of 
English coal-miners, and in the United States Wainwright and Nichols 1 
found that in Scranton, Pa., tuberculosis is about two-thirds less fre- 
quent among miners than among all other occupied males. Some 
writers have attempted to explain this paradox by assuming that coal 
dust possesses antiseptic properties, and is rather a protection against 
tuberculosis. Cornet suggests that in coal mines the air is humid 
and thus prevents desiccation and pulverization of sputum, which is, 
of course, far-fetched. 

More noteworthy is it that street-sweepers and coachmen, in spite 
of exposure to excessive inhalation of dust, are not excessively liable 
to phthisis. Cornet concludes from this fact that the dangers of infec- 
tion in the street are nil. Sommerfeld has shown that in Berlin the 
street-sweepers have only half the rate of mortality from phthisis 
when compared with the mortality of the working classes in that city. 
In New York City, where several years ago considerable agitation was 
made in favor of protecting the street-sweepers against the excessive 
morbidity and mortality from tuberculosis, statistics have not borne 
out these contentions. Hoffman's 2 statistics, gathered for a monograph 
on the excessive mortality from consumption in occupations exposed 
to municipal and general dust, show that evidently "the recorded 
mortality from consumption among men in this employment is not 
decidedly excessive." 

Another kind of dust which is harmless in this regard is limestone, 
and also plaster of Paris. In England it has been found, according to 
Edgar L. Collis, 3 that masons in districts where limestone is worked 
do not suffer from phthisis in excess, while masons in districts where 
sandstone is worked are peculiarly liable to succumb to this disease 
and have a shorter prospect of life. Halter and Garb have observed 
the same to be the case in Germany, and G. Fisac 4 reports that in 
Spain the workers in quicklime and plaster of Paris are immune to 
tuberculosis despite the fact that they live in squalid dwellings and 
are underfed. He believes that their immunity is due to the inhala- 
tion of dust containing lime. 

That the chemical composition of the dust is of more importance 
than the dust itself is well shown by Collis in his Milroy Lectures for 
1915. He finds that when phthisis occurs as a result of inhalation of 
mineral dust, it is always associated with exposure to dust containing 
crystalline silica, though he could find no definite relation between 
the amount of dust present and the prevalence of phthisis. As to 
why coal dust, lime, plaster of Paris, etc., should be harmless in this 

1 Am. Jour. Med. Sc, 1905, cxxx, 405. 

2 Bulletin of Bureau of Labor, November, 1908, p. 633. 

3 Public Health, 1915, xxviii, 252, 292; xxix, 11. 

4 Rev. de hig. y de tub., 1909, v, No. 54, 



OCCUPATION 111 

regard, while flint, slate, iron, tin, lead, etc., do produce pulmonary 
tuberculosis, we are at a loss, and it may be worthy of further study. 

Another point brought out by Collis is that phthisis encountered 
among workers at dusty occupations is actually due to the inhala- 
tion of the dust, and not to their mode of life. Outdoor workers inhaling 
dangerous dust succumb, while careless indoor workers at dusty occu- 
pations inhaling dust containing no silica, or metallic fragments, are 
not excessively liable to phthisis. He finds that "dust phthisis is 
peculiar in showing a low degree of infectivity among contacts not 
exposed to dust inhalation." In the lead -mining districts of England 
there is a larger proportion of widows than in any other place in the 
kingdom. Haldane observed among tin-miners that "the wives and 
children of these men never seem to be affected, although occupying 
the same room as the affected men, who never go to the hospital but 
sit at home and expectorate sputum loaded with tubercle bacilli." 
Barwise noted the same phenomenon among grits tone- workers in 
Derbyshire, and it is also true of stone-masons, according to Collis. 

This shows clearly that certain forms of dust are capable of waking 
up dormant tuberculous lesions in the workers; but their wives, who 
have assuredly been infected with tubercle during childhood, cannot 
be reinfected with the bacilli expectorated by their husbands. It 
entirely agrees with our modern views of tuberculous infection, and 
with the experience of the difficulty or impossibility of reinfection 
which is spoken of in Chapter V. 

It thus appears that occupation per se cannot be considered as pre- 
disposing to phthisis, with the exception of those which involve expo- 
sure to metallic, and certain kinds of mineral dust. But even in these 
there are exceptions, as we saw, with street dust, coal dust, lime-stone, 
plaster of Paris, etc. Thus, there has been found a relation between 
the wages paid to workmen and the incidence of phthisis among them. 
B. S. Warren's 1 study of conditions in the United States Government 
printing and engraving plants shows that despite the fact that they 
are badly overcrowded, with poor ventilation, etc., the mortality from 
tuberculosis is rather low among the employees. The reason he assigns 
is that they receive good wages. He finds from census statistics that 
low wages go hand-in-hand with a high tuberculosis mortality. The 
difference in wages or income means a difference in nutrition, social 
contentment, and general welfare which render the farm laborer more 
susceptible to phthisis than his employer, and the cotton-mill opera- 
tive more than the general population. Similarly, he finds that of 
deaths among males reported by the Census Bureau for 1909, giving 
the occupation of the deceased, 14.7 per cent, were from tuberculosis, 
as against 20.9 per cent, among females. The reasons for this disparity 
are many, but undoubtedly the inadequate wages paid to women are 
responsible for a considerable portion of the phthisis among female 
workers. 

1 Tr. Nat. Assn. Study and Prevent. Tuberc, 1913, ix, 153. 



112 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 



TRAUMATIC TUBERCULOSIS. 

Injury as a Cause of Phthisis. — That traumatism may determine 
the localization of extrathoracic tuberculosis — of the bones, joints, 
glands and meninges — is a well-known and accepted clinical fact sup- 
ported by the results of animal experimentation. But that a local 
injury to the chest may be the exciting cause of phthisis is not generally 
appreciated to the extent it deserves. It seems that the older medical 
literature only rarely referred to this subject, and Grasser could only 
find reports of about 50 cases before 1903. In the Prussian Army it 
was observed that among 6924 cases of phthisis, 95 began after an 
injury, and of these 79 had sustained contusions of the chest. This 
would indicate that it is more frequent than was formerly appreciated. 

In surgical tuberculosis traumatism is more often the exciting cause. 
Leon Giroux 1 gives the following statistical figures: Jeannel found 
that 5 per cent, of cases are post-traumatic; Wilner, 6 to 7 per cent.; 
Pietrzikowski, 8 per cent.; Lemgey, 8.81 per cent.; Estor, 9.5 per cent.; 
Hahn, 31 per cent, (of hip-joint disease); Honsele, 14 per cent.; Konig, 
20 per cent.; Voss, 21.5 per cent.; Horzetsky, 44 per cent, (tubercu- 
losis of the spinal column); Taylor, 52 per cent.; and finally Bauer, 
almost 100 per cent. 

It is obvious that an injury per se cannot cause tuberculosis of a 
bone or a joint. Tubercle bacilli must be present. But in the light of 
our present knowledge of phthisiogenesis it is clear that many, if not 
most, persons harbor some latent or healed tuberculous foci with viru- 
lent tubercle bacilli which an injury may reawaken into activity. 
Kiilbs has shown that contusions of the chest often cause lacerations 
and hemorrhages of the pulmonary parenchyma, even when no visible 
hemoptysis occurs, and such lacerated areas may offer a favorable 
soil for the implantation of tubercle bacilli, just as an injury to a joint 
or a fractured rib. 

In his monograph on this subject, Richard Stern 2 gives the following 
direct and indirect possibilities of phthisis after injury: (1) A periph- 
eral tuberculosis of a bone or joint may be produced and this may 
influence unfavorably a preexisting tuberculous lesion in the lung; 
(2) the unfavorable influence of loss of blood; (3) peripheral throm- 
bosis may be caused, followed by pulmonary infarction which may 
ultimately end in secondary tuberculous infection; (4) the deleterious 
effects of a long stay in bed, especially in hospitals; (5) psychic depres- 
sion, reducing the general resisting powers and producing changes in 
the constitution of the patient as a result of the accident. 

In persons known to be tuberculous the disease may be aggravated 
by an injury, as I have seen in several cases, and lead to a fatal termi- 
nation. Especially is this the case when hemoptysis is caused by the 
injury. Traumatism may also produce pleurisy, usually dry, but 

1 La tuberculose pleuro-pulmonaire traumatique, Paris, 1815, p. 8. 

2 Die traumatische Entstehung innerer Krankheiten, Jena, 1910, 



TRAUMATIC TUBERCULOSIS 113 

occasionally with an effusion. Pneumothorax is another possible 
result of an injury to the chest. In non-tuberculous traumatic pneu- 
mothorax the rent in the pleura heals quickly and the air is absorbed, 
but in those with a preexisting tuberculous lesion in the lung, active 
or dormant, the usual course of spontaneous pneumothorax, hydro- 
thorax, pyopneumothorax, etc., may be followed. 

The intensity of the injury should not be taken as a measure of the 
probability of its relation to phthisis subsequently developed, as has 
been pointed out by Wolff-Eisner. After violent injuries to bones, 
especially those resulting in fractures, tuberculous osteomyelitis is 
hardly ever observed, though slight injuries to bones may be followed 
by local tuberculosis. In the same manner, as I have seen in several 
cases, a slight injury to the chest may flare up a latent tuberculous 
process. In persons known to be healthy this is not uncommon. John 
B. Hawes 1 points out that after the autumn football season some 
players develop consumption as a result of injuries received on the 
football field. The special diet usually prescribed by the trainer, as 
well as the excessive exertion for months during the training period, 
undoubtedly reduces the resisting powers of even gridiron heroes. On 
the other hand, during the World War, injuries to the chest, especially 
those in which the wounds were penetrating, lacerating the pleura and 
lungs, were only rarely observed to be followed by symptoms of 
phthisis. 

The site of the lesion provoked by an injury is not necessarily at 
the point affected by the blow. Many authors have reported lesions 
by contrecoup. An acute general or miliary tuberculosis may also 
result from breaking up of a latent lesion and letting loose tubercle 
bacilli into the blood stream. Hemoptysis is not absolutely essential 
to establish the relationship between the injury and the phthisis, 
because laceration of the lung may occur without causing hemorrhage. 
When hemoptysis occurs, the quantity of blood expelled is no criterion 
of the size of the torn vessel. Nor must there remain any external 
marks on the chest wall because an injury may lacerate the lung or 
pleura without leaving any external traces. 

The appearance of clinical symptoms of phthisis may be delayed 
for some time. Of course, in cases of quiescent lesions which are 
activated as a result of traumatism, the aggravation in the condition 
of the patient and the extension of the process may appear soon after 
the accident, and hemoptysis may appear even immediately. In many 
cases the bleeding is, however, delayed several hours or days, which is 
to be expected considering the pathology of hemoptysis. But in appar- 
ently healthy persons the symptoms of phthisis may appear many 
months or years later. 

Hawes reports several cases in which phthisis developed from two 
to ten years after the injury. 

1 Boston Med. and Surg. Jour., 1913, clxviii, 83. 



114 FACTORS PREDISPOSING TO EVOLUTION OF PHTHISIS 

The appearance of tubercle bacilli in the sputum may be delayed 
for weeks or months, and this does not militate against the traumatic 
origin of the disease. We know that in many cases of spontaneous 
phthisis bacilli are found only months, or even years, after the onset 
of the disease. 

It takes about eight weeks for a tubercle to develop and one tubercle 
is by far not enough to give symptoms or signs by which it can be 
recognized by the patient or the physician. In fact, when a few days 
after an injury signs of phthisis are found, especially tubercle bacilli 
are found in the sputum, we may conclude that we are dealing with a 
preexisting disease which was, at most, aggravated by the accident. 
But in cases in which the symptoms, such as fever, emaciation, cough, 
expectoration, etc., make their appearance three to six months after 
the injury in a person known to have been well before the accident, 
and the physical signs appear even later, it is clear that there was a 
causative relation between the injury and the disease. German author- 
ities have limited the time for the appearance of the symptoms after 
the injury to six months, although there are undoubtedly exceptions 
which must be judged on their individual merits. 

Clinical Manifestations of Traumatic Tuberculosis. — In many cases 
symptoms of pleurisy make their appearance within a few days — 
chilly sensations, fever, pain in the chest, etc. Usually these disappear 
within some days, and are followed by symptoms of phthisis. In 
some instances there occurs a pleural effusion, which runs its course in 
the same manner as the average case of this type not due to traumatism. 
Hemoptysis is not so frequent as would be expected, excepting in those 
who have suffered from pronounced phthisis for some time and the 
traumatism was the exciting cause of the hemorrhage. In such cases 
the amount of blood lost may be considerable. In most cases, however, 
the amount of blood lost is rather slight, a few mouthfuls. 

Usually the lesion is found right under the site of chest wall where 
the injury was inflicted, but at times it is found far away from it, even 
in the opposite side, by contrecoup, as was already stated. This is an 
important point in cases in which responsibility for the disease must 
be established. In several cases of basal phthisis, the lesion being 
located in one of the lower lobes, I found it due to injury. In 1 case 
it was the kick with the hoof of a horse; in another, a fall on side 
sustaining a contusion of the chest. 

The course of the disease may be acute, subacute, or chronic, and 
any clinical form of the disease may be observed. In fact, there is no 
difference to be discerned in this regard between traumatic and spon- 
taneous phthisis. 

The writer has observed a few cases of acute miliary tuberculosis, 
and acute pneumonic phthisis, following injuries. In such cases it is 
clear that the injury was inflicted on some part of the body in which 
there was a latent or dormant tuberculous process. In 1 case the 
patient was struck with a bottle over the chest. He immediately 



TRAUMATIC TUBERCULOSIS 115 

had a copious pulmonary hemorrhage, and on the next day the tem- 
perature rose to 104° F. which kept up for about six weeks, accom- 
panied by symptoms and signs of acute pneumonic phthisis, terminat- 
ing fatally. F. Parkes-Weber 1 reports a case in which an injury set 
free a caseous focus in the epididymis producing acute and fatal 
phthisis. 

Surgical injuries may thus be effective in producing acute miliary 
tuberculosis. This is seen in cases in which a patient is operated upon 
for some chronic tuberculous disease of a joint, bone, or gland, and he 
develops acute tuberculous disease which is rapidly fatal. I have seen 
2 cases of this sort developing after bloodless operations and manipu- 
lations of joints. Such cases have also been reported by Parkes- 
Weber, Urban, 2 Orth, 3 and others. Among these cases may also be 
included the frequent development of tuberculosis of an acute and 
malignant type observed in women after childbirth and abortions. 
Parkes-Weber also mentions massage as a possible etiological factor 
in reactivating dormant tuberculous processes and producing acute, 
progressive tuberculosis. 

Traumatic tuberculosis has of late become a very important medico- 
legal topic, not only in cases in which damages are asked for tubercu- 
lous lesions induced by injuries, but also because of the" recent legis- 
lation in many States concerning workmen's compensation. The 
responsibility is to be fixed in cases in which tuberculosis has been 
determined by the accident, and in those in which preexisting tuber- 
culous disease has been aggravated by the injury. 

1 Traumatic Pneumonia and Traumatic Tuberculosis, London, 1916. 

2 Munchen. med. Wchnschr., 1899, xiv, 346. 

3 Berlin, klin. Wchnschr., 1914, xli, 246. 



CHAPTER V. 
PHTHISIOGENESIS. 






Tuberculosis vs. Phthisis. —After infecting an animal with tubercle 
bacilli, we know exactly what morbid phenomena to expect. On 
injecting into the peritoneal cavity of a guinea-pig a certain quantity 
of the pure culture of tubercle bacilli, tuberculous peritonitis soon 
develops, followed by tuberculosis of other organs — the spleen, the 
liver, the kidneys, etc., until it finally succumbs. But what will happen 
after a human being is infected in the usual spontaneous manner we 
cannot prognosticate with any degree of certainty. The individual 
may pass through life without showing any morbid manifestations 
which can be attributed to the infection. In fact, the vast majority 
of people have been infected during their childhood and are none the 
worse for their experience, as has already been shown. A large propor- 
tion of those in whom distinct lesions of a tuberculous character have 
been found at the autopsy knew nothing about it during their life. 
On the other hand, in a certain proportion the infection is followed 
sooner or later by symptoms of some clinical form of tuberculosis. 

This is, however, not the only difference between experimental 
tuberculosis and spontaneous phthisis as we meet it in human beings. 

It appears that phthisis is a disease met with exclusively in human 
beings and rarely, if ever, in the lower animals; certainly not in animals 
'which have been injected experimentally in the laboratory, be it by inocu- 
lation, ingestion or inhalation of tubercle bacilli. In guinea-pigs, rab- 
bits, etc., in whom spontaneous tuberculosis is exceedingly rare, only 
nodular tubercles, consisting of avascular, cellular masses are formed 
after experimental infection; while spontaneous human phthisis is 
mainly a productive and exudative inflammatory process of the lungs 
in which there may, or may not, be any of the characteristic tuber- 
culous cell-proliferation. In other words, in animals it is general or 
miliary tuberculosis that we find, and this is also rarely met with in 
humans. "Real pulmonary tuberculosis," says von Hansemann, 1 "in 
the anatomical sense, is always part and parcel of general tuberculosis 
of all the organs in the body. Pure and isolated pulmonary tubercu- 
losis in the anatomical sense, i. e., in which there are no other tuber- 
culous changes in the lungs than the development of submiliary tuber- 
cles, never occurs so far as my experience goes. But it is a noteworthy 
fact that from this disease, which in reality alone deserves the name 
pulmonary tuberculosis, phthisis never evolves. I know of no case 
in my own experience, nor from medical literature, in which the disease 

1 Berl. klin. Wchnschr., 1911, xlviii, 1. 



PHTHISIS AS A DISEASE ACQUIRED DURING CHILDHOOD 117 

began as acute miliary tuberculosis in the anatomical sense, and then 
turned into pulmonary phthisis." But phthisis may be complicated 
by general miliary tuberculosis. This often occurs before the fatal 
termination of the case. 

In the same sense we find that Ribbert 1 makes a sharp distinction 
between experimental tuberculosis in animals and phthisis in human 
beings: "It is undoubtedly a fact that tubercles may be produced in 
the lungs of animals which are made to inhale dust containing tubercle 
bacilli. But, (1) the disease thus produced is not the same as that 
in human beings; (2) we cannot, without further proof, conclude that 
human beings are infected in the same manner. The conditions under 
which humans inhale tubercle bacilli are, at least from the viewpoint 
of quantity, distinctly different from those prevailing during experi- 
mentation. It can neither be proved that individuals always inhaled 
tubercle bacilli before becoming sick nor that the latter settled pri- 
marily in the particular organ in which they proliferated. Neither the 
clinical nor the anatomical findings sufficiently support such a view. 
It is self-understood that I do not in the least deny that in man also 
disease may directly follow the inhalation of tubercle bacilli, but it is 
a question how often this takes place. From mere possibility to uncon- 
trovertible proof which will cover all tuberculous diseases of the lungs, 
is quite a distance." "Pulmonary phthisis," says Bacmeister, 2 "is a 
disease found exclusively in adult human beings; it never occurs spon- 
taneously in animals, nor has it ever been produced experimentally." 

If we want to apply unequivocally the experimental findings to 
man we must first demand that infection of animals should result in 
isolated apical lesions which should extend gradually downward in 
the lung in the typical chronic manner. All other forms of tubercu- 
losis which are produced experimentally in the lungs of animals do 
not prove much, because their morbid anatomy diverges so much from 
the changes found in human phthisis. 

The problem why the. human adult, after infection with tubercle 
bacilli, develops phthisis, a disease Unknown in early childhood and 
among the lower animals, has not yet been solved to the satisfaction 
of all who are entitled to an opinion. Freund, Hart, Bacmeister, and 
others believe that pressure of a short rib or an ossified first costal 
cartilage upon the apex of the lurig is responsible for the apical locali- 
zation of phthisis (see p. 95). We have, however, shown that this 
theory does not explain everything connected with the problem. 
Various other theories have been promulgated to explain the origin 
of human phthisis. 

Phthisis as a Disease Acquired during Childhood. — During recent 
years the theory that phthisis is a late manifestation of tuberculosis 
acquired during childhood has been gaining ground. Behring, 3 basing 

1 Die Ausbreitung der Tuberkulose im Korper, Marburg, 1900. 

2 Die Entstehung der menschlichen Lungenphthise, Berlin, 1914, p. 35. 

3 Deut. med. Wchnschr., 1903, xxix, 689; British Med. Jour., 1903, ii, 993. 



118 PHTHISIOGENESIS 

his opinions on experiments with guinea-pigs, maintains that a single 
infection cannot result in phthisis. He says that phthisis is the result 
of reinfection of a person who was already once infected during infancy, 
mainly through deglutition of milk derived from tuberculous cows. The 
bacilli pass through the gastro-intestinal tract into the lymphatics 
where they remain for years in an avirulent or mildly virulent state, 
and in the adult, as a result of some intercurrent affection, they become 
again virulent and cause phthisis. " Phthisis is but the last verse of 
the song, the first verse of which was sung to the infant at its cradle." 1 

Hamburger's 2 conception of phthisis is also that it must not neces- 
sarily be preceded by recent infection, but that it is rather a reawaken- 
ing, or an exacerbation, of an old, "healed," or latent tuberculous 
process. He points out that tuberculosis runs a different course in 
children from that in adults — pulmonary phthisis which is so frequent 
in adults is exceedingly rare in children. But we know that most people 
have passed through a tuberculous infection during childhood. Under 
the circumstances the inference is justified that pulmonary phthisis is 
invariably preceded by a tuberculous infection many years before its onset. 

To Hamburger the course of phthisis is similar to that of syphilis, 
with periods of health and quiescence or latency, interrupted or fol- 
lowed by periods of acute or subacute exacerbations. The primary 
lesion is inoculated during childhood, before the individual reaches his 
tenth year of life. During infancy this primary focus, if massive infec- 
tion has taken place, or the resistance is low, may cause miliary tuber- 
culosis or hematogenic metastasis, but in the vast majority of people 
it heals or remains dormant. In those in whom metastatic deposits of 
tubercle bacilli are distributed in various parts of the body, secondary 
tuberculous manifestations make their appearance, consisting in tuber- 
culosis of the glands, bones, joints, meninges, etc. After the tenth 
year the tertiary manifestations are met with, consisting in the various 
forms of chronic pulmonary phthisis, tuberculosis of the larynx, tumor 
albus, certain cases of joint diseases, of the kidneys, lupus vulgaris, 
tuberculous iritis, adhesive pleurisy, etc. These last are practically 
never seen in infancy and early childhood, only after the disease has 
lasted for many years they may appear, just as the late manifestations 
of syphilis— tabes, general paralysis, etc., are only rarely seen in early 
youth, although syphilis is quite frequent at that period of life. 

Phthisis is thus, according to Hamburger, an exacerbation of tuber- 
culosis which has been acquired during early childhood and remained 
latent for many years until some exciting cause, or a reduction in the 
powers of resistance, has brought about conditions favorable for its 
development. 

Immunity or Allergy. — The view of phthisiogenesis which has been 
gaining ground of late, and which is apparently based on a sound 

1 Einfuhrung in die Lehre von der Bekampfung der Infektionskrankheiten, Berlin, 
1912, p. 354. 

2 Die Tuberkulose des Kindesalters, Leipzig, 1912. 



IMMUNITY OR ALLERGY 119 

foundation, has been formulated by Paul Romer to the effect that 
phthisis is a manifestation of immunity against tuberculosis ivhich has 
been acquired by an infection during early childhood. 

It appears that the observations made in most of the transmissible 
diseases that one attack renders the individual immune against renewed 
infection with the same virus, hold good in tuberculosis. Behring, 
Romer, Calmette, Metchnikoff, Hamburger, Bushnell, and others, have 
shown that the mild infections with tuberculosis during childhood endow 
the organism ivith a certain amount of immunity against further and 
renewed exogenic infection with tubercle bacilli, so that an individual 
with a healed or latent lesion, acquired during early childhood, is 
immune to these microorganisms. Repeated infection with the same 
virus may be reinfection or superinfection. By superiufection is under- 
stood a second infection at a time when the lesions produced by the 
first infection have not healed, while reinfection implies a new infec- 
tion when the lesions produced by the first have completely healed. 
"Inasmuch as we may accept as a great probability that in tubercu- 
losis healing in the strict scientific sense never occurs," says Ham- 
burger, 1 "all repeated infections in tuberculosis are to be considered 
superinfections." We use the word reinfection because this term has 
gained extensive currency in medical literature. 

Experimental Proofs of Immunity. — Experimentally acquired immu- 
nity by an inoculation of tuberculosis has been proved to exist by the 
researches of Koch, 2 Behring, Romer, 3 Hamburger, Webb and Wil- 
liams, 4 Rossignol, Krause and Volk, and many others. When a 
healthy guinea-pig is inoculated with tubercle bacilli in pure culture, 
the wound closes up within a couple of days and seemingly heals up. 
But about ten or fourteen days later there appears at the site of the 
inoculation a hard nodule which soon breaks down, leaving an ulcer 
which persists till the animal dies. It is different when a tuberculous 
animal is inoculated with tubercle bacilli. The wound also heals, but 
no nodule is formed and a few days later the point of inoculation 
becomes indurated, dark in color all around the punctured point to 
about 1 cm. in diameter. During the next few days the spot becomes 
necrotic and the involved tissues are shed, leaving a flat ulcerated 
area which usually heals quickly and permanently. Moreover, while 
after infecting a healthy animal the regional lymph glands become 
swollen, this does not occur after reinfection of a tuberculous animal. 

The work of Romer 5 and Hamburger 5 along these lines has recently 
changed our conception of tuberculous infection and suggested prophy- 
lactic measures which are actually revolutionary. They have found 
that reinfection is as difficult and even as impossible in tuberculosis as 

1 Med. Klinik, 1915, xi, 34. 

2 Deutsch. med. Wchnschr., 1891, xvii, 101. 

3 Beitr. z. Klin. d. Tubeik., 1910, xvii, 287; 1912, xxii, 301. 

4 Jour. Med. Research, 1911, xxiv, 1. 

6 Beitr. z. Klin. d. Tuberk., 1910, xvii, 287, 383; 1912, xxii, 265, 301. 
6 Ibid., 1910, xvi, 271. 



120 PHTHISIOGENESIS 

in syphilis. All modes of infection were tried, inoculation, feeding 
and inhalation of tubercle bacilli in dust or spray, and contact infection, 
which are akin to the usual modes of spontaneous infection in human 
beings, but no new tuberculous lesion could be produced in tuberculous 
animals, while the healthy controls were infected and succumbed to 
the disease is some form. Not only were guinea-pigs and rabbits — 
which are very susceptible — thus tried, but sheep which are not as 
vulnerable to tubercle bacilli, and also dogs which are strongly refrac- 
tory, and monkeys which display the same degree of susceptibility as 
man. Romer found that when a healthy sheep is infected with a certain 
dose of tubercle bacilli, it succumbs within eight weeks to acute pul- 
monary tuberculosis, but the same dose is harmless in a tuberculous 
sheep. In monkeys the results were the same. Hamburger and 
Toyofuko have proved that infected guinea-pigs are not only immune 
to inoculation but also to inhalation which is deadly to healthy control 
animals. It appears from Romer's studies that this immunity is not 
transmitted by heredity, even when displayed by pregnant mothers. 

It has also been found that this immunity is not only true of exogenic 
superinfection, or additional infection with bacilli of another strain, 
but also of superinfection with bacilli taken from their own lesions. 

Another important point was established by the experimental 
investigations of Romer and Hamburger: If the reinfecting dose of 
tubercle bacilli is small, perfect immunity is found — the point of inocu- 
lation heals quite soon. As a rule, the immunity is observed in animals 
which have been tuberculous for some time, three or four months. 
But if the reinfecting dose of tubercle bacilli is massive, it soon causes 
death of the animal. 

These experimental researches are well founded, having been con- 
firmed by many workers in various countries, so that at present they 
are as firmly established as anything else we know about spontaneous 
and experimental tuberculous infection. But there arise several prob- 
lems of immense interest in our study of phthisiogenesis. Knowing 
well that the vast majority of human beings have been infected with 
tubercle bacilli during childhood, even those who have no clinical 
evidence of phthisis, we may justly ask, Can adults be infected with 
tuberculosis at all? The bearings of this problem on prophylaxis are 
enormous. How does phthisis develop from the lesions acquired during 
infancy and childhood? Is it due to a second infection immediately 
before the onset of the disease, or do the old, hitherto dormant lesions 
for some reason flare up and begin to extend? 

Modes of Reinfection in Human Beings. — A person who has once 
been infected with tubercle bacilli may be reinfected with the germs 
which he harbors within his body, or with bacilli which have grown 
in the body of some other person, or in an animal. In the case of endo- 
genic or autogenic reinfection the process may be very simple: A 
softened tuberculous lesion in the lung is ruptured into a bronchus, 
and during cough the tuberculous material is carried along the bronchial 



REINFECTION IN HOSPITALS FOR CONSUMPTIVES 121 

tree to some other part of the lung where it is deposited and, taking 
root, it produces a new lesion. In this manner there may also be pro- 
duced laryngeal and intestinal tuberculosis, the latter from swallowed 
sputum. But endogenic reinfection is not always bronchogenic; it 
may also be hematogenic — a tuberculous lesion may break into a 
bloodvessel and then bacilli are carried to various parts of the body; 
or it may be lymphogenic; the tuberculous material is carried by the 
lymphatics, infecting the lymph glands, etc. 

Exogenic reinfection should be very common, if it takes place at aU. 
The bacilli are ubiquitous, and one suffering from any form of tuber- 
culosis is evidently predisposed, otherwise he would have escaped the 
disease, despite the first infection. Infection is exceedingly easy, as is 
evident from the fact that when a child free from tuberculosis is brought 
in contact with a consumptive, it is soon infected. Hamburger even 
reports a case where exposure of an infant for one hour was effective 
in infecting it. We also see this to be a fact in adults : When indi- 
viduals free from tuberculous infection dating back to childhood, as is 
the case with primitive peoples, come into contact with tuberculous 
people, they are soon infected and succumb in a short time. 

Granting these premises, which are based on carefully observed 
facts, we may be able to study the problem of reinfection in man 
clinically, even though the experimental method is, for obvious reasons, 
closed to us. All we have to do is to inquire into the frequency of exo- 
genic and endogenic superinfection and reinfection in tuberculous 
patients who are inmates in hospitals for consumptives; the frequency 
of tuberculosis among those who are apparently healthy but live with 
consumptives; and also the effects of tuberculous infection on persons 
who are known to have escaped infection during childhood. 

Reinfection in Hospitals for Consumptives. — Clinical experience has 
shown that it is one of the rarest things in medicine that a person 
should have one of the exanthemata twice during his life. It has also 
been observed that in a ward filled with cases of scarlet fever, smallpox, 
etc., there is no danger that patients suffering from the more malignant 
types of the disease should transmit the virus to those who are passing 
through a mild or abortive attack, of the same disease. In nearly all 
contagious and infectious diseases we find that during the existence 
of the malady the patient is immune against exogenic reinfection with 
the virus of the same disease. The same is true of the exceedingly 
chronic transmissible disease, syphilis. 

The experience in hospitals harboring large numbers of consumptives 
should give us information along these lines about tuberculosis. Here 
the patients have all the opportunities for superinfection with bacilli 
derived from other patients. For it must be agreed that despite the 
scrupulous cleanliness observed at present in sanatoriums and hospitals, 
it is impossible to avoid droplet infection when many patients are 
brought into intimate contact. In fact, when caged guinea-pigs are 
kept in scrupulously clean wards they soon contract tuberculosis. 



122 PHTHISIOGENESIS 

It has, however, never been observed that a mildly infected patient 
living in an institution should be reinfected from one severely infected 
who shares the ward with him, even when the latter expectorates 
myriads of virulent bacilli and offers exceptional opportunities for 
droplet infection. 

Many non-tuberculous patients remain in sanatoriums for months, 
yet it has not been observed that one should become tuberculous 
because of his sojourn in the hospital. This is the reason why hospitals 
and sanatoriums do not separate the "open" from the "closed" cases, 
i. e., those who expectorate sputum reeking with tubercle bacilli from 
those who do not, in spite of the fact that many physicians are con- 
vinced that droplet infection is a potent factor in disseminating 
tuberculosis. 

The hospital staff, including physicians, especially laryngologists, 
nurses, orderlies, etc., come in close contact with the patients in sana- 
toriums and should become infected if adults, presumably infected 
during childhood, could be reinfected with tubercle bacilli. But, if 
experience of thousands of people in these callings counts for anything, 
they do not show a higher mortality nor morbidity from tuberculosis 
than persons in other occupations. The first statistics bearing on this 
problem were published by C. Theodore Williams 1 who showed that 
long before the discovery of the tubercle bacillus, and before any 
precautions were taken to prevent the transmission of the disease, no 
case of infection of the hospital staff had been observed. From 1846, 
when the Brompton Hospital for Consumptives was opened in London, 
to 1882 "statistics showed that among the physicians, assistant 
physicians, hospital clerks, nurses and others, to the number of several 
hundred, who had served in the hospital (not few of them having lived 
in it for a number of years continuously), phthisis had not been more 
common than it may be expected to be on the average among the civil- 
population of the town." In a later paper Williams 2 brought these 
statistics down to 1909 and found that conditions remained the same. 
But while during recent years the improvements in hygienic conditions 
and disinfection of sputum may be the cause of the rarity of phthisis 
in the hospital staff, this cannot be said to have been operative before 
1882. 

Similar statistics are available for hospitals in Germany and France, 
published by Aufrecht, 3 Freymuth, 4 Brunon, 5 Saugman, 6 and others, 
and brought together by the author 7 in a paper on hospital infection. 
Instructive data on the subject have been collected by Saugman from 
many sanatoriums in various countries. He finds that even among 
laryngologists, who are exposed to infection more than any other 

1 British Med. Jour., 1882, p. 618. 2 Ibid., 1909, ii, 433. 

3 Miinchen. med. Wchnschr., 1908, xlv, 158. 

4 Beitr. z. Klin. d. Tuberk., 1911, xx, 231. 

5 La tuberculose pulmonaire, Paris, 1913, p. 59. 

6 Ztschr. f. Tuberk., 1905, vi, 125; 1907, x, 224. 

7 Am. Med., 1915, xxi, 607. 



MARITAL PHTHISIS 123 

class, the morbidity and mortality from tuberculosis are less than would 
be expected. He concludes that tuberculosis is extremely rare among 
those who are engaged among consumptives; physicians and laryngolo- 
gies who had been healthy before entering upon their duties, remain 
so. "It is not dangerous for healthy adults to be coughed at by 
patients suffering from pulmonary or laryngeal tuberculosis" con- 
cludes Saugnian. 

Such facts have been quoted to disprove the transmissibility of 
tuberculosis, but in the light of our present knowledge they merely 
prove that reinfection is impossible. 

Marital Phthisis. — Again, bearing in mind the ease with which 
tuberculosis is transmitted to persons who have not been infected 
previously, it should be expected that the vast majority of husbands 
of tuberculous wives, or healthy wives of tuberculous husbands should 
acquire the disease. This, we know, is the case with syphilis, in which 
the active disease is almost invariably transmitted to the unaffected 
consort, excepting when the latter has been infected before marriage. 
But for a long time it has been a mystery why phthisis in both husband 
and wife is very rare in spite of the fact that they probably come into 
more intimate contact than even father and child. Even in families 
in which most or all of the children are affected with tuberculosis it is 
exceedingly rare to find that both the mother and the father should be 
sick with the disease. Formerly this fact was used as a strong argument 
against the transmissibility of tuberculosis, but now we understand 
that it is due to the immunity acquired by an infection which has not 
been effective in producing phthisis. 

For many years the writer was physician to a charitable society. 
having under his care annually 800 to 1000 consumptives who lived 
in poverty and in want, in overcrowded tenements, having all oppor- 
tunities to infect their consorts; in fact, most of the consumptives 
shared their beds with their healthy consorts. Still, very few cases were 
met in which tuberculosis was found hi both the husband and the 
wife. Widows, whose husbands died from phthisis, were only rarely 
seen to develop the disease. 

This experience is not unique. Mongour 1 found that among 440 
married couples, in which one of the consorts was sick with tuberculosis, 
there were only 16 in which the partner was also phthisical, i. e., 4 per 
cent. Thorn 2 reports 402 couples with only 12. or 3 per cent., in 
which infection of the consort had taken place in all probability. 
I. Burney Yeo 3 found marital phthisis comparatively rare, basing Ins 
deductions on particulars collected of 1055 cases of consumption. He 
cites figures of J. R. Bartlett, Herman Weber, and others and concludes: 
" Taking these figures for what they are worth, it seems certain that 
the communication of consumption from wife to husband, even among 

1 Cong. Intern, de la Tubereulose, Paris. 1905. i. 413. 

- Ztsehr. f. Tuberkulose. 1905. vii, 12. 

5 British Med. Jour., June 17, 18S2, p. S95. 



124 PHTHISWGENESIS 

the class in which the conditions of life favor to the utmost the com- 
munication of contagious disease, is very rare; while it would seem 
that communication from husband to wife is more frequent." Pope, 1 
Pearson, 2 Elderton, and Goring have made careful statistical studies of 
this problem in England and arrive at the conclusion that the chances 
of tuberculosis occurring in both consorts are about the same as insanity, 
and a German writer has shown that cancer in both consorts is more apt 
to occur than phthisis. In a recent statistical study by Levy, 3 compris- 
ing 317 married couples which lived in poverty, 34 per cent, sharing the 
bed, possible marital infection could be traced only in 2.8 per cent. He 
points out that when marital phthisis does occur, it is characterized 
by a favorable course of the disease in the secondary cases, and soon 
after the actively diseased partner is removed, the infected consort 
recovers his or her health. Haupt found among 1553 tuberculous 
couples that 106, or 7 per cent., were both affected. This being the 
highest percentage recorded, it is essential to remember that it is 
exactly the proportion in which humanity suffers from the disease. 
This problem was investigated by the author 4 in New York City among 
the poor and dependent, living under trying economic and sanitary 
conditions. Among 170 couples in which one of the consorts w T as 
tuberculous, it was found that only in 2.5 per cent, were both the hus- 
band and the wife phthisical; this notwithstanding the fact that a large 
majority lived very closely together, even sharing the bed. It has been 
my impression when investigating this problem that if under such con- 
ditions infection has not taken place, it cannot occur in any other 
adults. 

Romer mentions that life insurance companies in Germany, basing 
their action on statistical experience, do not reject persons because of 
a history of exposure to infection, or those who live with tuberculous 
consorts. George Florschutz 5 , in his work on insurance selection, says 
that " in medical selection one must certainly consider the risk of infec- 
tion when it is so evident as in conjugal intercourse, but in general, so 
far as life insurance is concerned, one may regard tuberculous infection 
as purely a matter of chance." He brings statistics "showing that of 
1428 deaths from tuberculosis, there were but 11 in which the husband 
or the wife of the deceased was tuberculous." 

In this connection it is important to mention a curious phenomenon, 
first mentioned by Petruschky 6 and which he named "mother immu- 
nity." A woman marrying a tuberculous husband begets children, most 
of w r hom either are sick w r ith, or die from, tuberculosis, but she remains 

1 A Second Study of Statistics of Pulmonary Tuberculosis. Marital Infection, London, 
1911. 

2 Tuberculosis, Heredity and Environment, London, 1912; The Fight against Tuber- 
culosis and the Death Rate from Phthisis, London, 1911. 

3 Beitr. z. Klin. d. Tuberk., 1914, xxxii, 147. 

4 Am. Jour. Med. Sc, 1917, cliii, 395. 

5 Medical Record, 1915, lxxxvii, 957. 

6 Ergebnisse d. Immuntatsforschung, 1914, i, 189. 



IMMUNITY ACQUIRED BY TUBERCULOUS INFECTION 125 

healthy. Gerald Webb 1 has observed the same condition,' though he 
is inclined to consider this as only a relative and not a complete immu- 
nity of the mothers, because they react to tuberculin, and he even found 
one of them to be herself a "carrier." The present writer has had 
many women of this type under his care. Analogous conditions are 
seen in men, which may be called " father immunity." A man marries 
a wife who dies from tuberculosis; he again marries and his second wife 
succumbs to the same disease. I know of one who had three wives die 
from tuberculosis, while he remained healthy. The children are usually 
tuberculous, or die from this disease. 

We have dwelt on these facts because they are very important points 
in phthisiogenesis: (1) tuberculous infection can only occur once; and 
(2) that phthisis evolves only in persons who are for one reason or 
another predisposed to the disease. Inasmuch as the non-phthisical 
consort has already been infected with tubercle bacilli during child- 
hood, all new opportunities for reinfection by cohabitation with a 
consumptive consort are of no avail to produce phthisis. It is his or 
her constitution that determines whether consumption will develop, 
aud not the opportunities for reinfection. 

Clinical Proofs of Immunity Acquired by Tuberculous Infection. — 
Many investigators have shown that tubercle bacilli circulate in the 
blood of a large proportion of consumptives, yet they do not manifest 
general or miliary tuberculosis, as would a priori be expected. The 
only plausible explanation is that inasmuch as they have already a 
tuberculous focus in some part of the body, this protects their other 
organs against renewed endogenic or exogenic reinfection, and the 
bacilli in the blood remain innocuous. 

A number of clinical facts, hitherto obscure, can be explained by 
this acquired immunity of the tuberculous to tuberculosis, and they 
confirm the assumption that experimental data obtained in animals 
hold good for man. Thus, in spite of the fact that so much sputum 
containing tubercle bacilli passes through the throat, tonsils, mouth, 
lips, etc., tuberculosis of these mucous membranes and the cervical 
glands is exceedingly rare in adults. Conversely, in former times 
physicians believed that scrofulous children were immune to phthisis 
and my observations lead me to the conviction that this is true today. 

Calmette 2 says : " Everyone knows that a local tuberculous suppura- 
tion occurring in a person with pulmonary tuberculosis ameliorates 
the condition of the patient and considerably increases his resistance. 
Inversely, it is rare that patients in whom pulmonary tuberculosis 
has had a rapid development have been attacked previously by sup- 
puration of the lymph nodes, or bony or cutaneous tissues, except in 
cases where an inopportune surgical operation has provoked infec- 
tion of the blood. It is a well-known fact that about a quarter of the 
persons suffering from lupus present the auscultatory signs character- 

1 Jour, of Laboratory and Clin. Med., 1916, i. 

2 Medical Record, 1908, lxxiv, 741. 



120 PHTHISIOGENESIS 

istic of pulmonary tuberculosis, and that these generally develop in 
them with very great slowness; likewise many lupus patients live to 
advanced age." Marfan also found that persons with healed tuber- 
culosis of the skin and glands never become phthisical, and Piery 1 shows 
that a certain number of children of tuberculous parentage display a 
veritable immunity against the grave and acute forms of tuberculosis. 
They are just the ones who present the alleged stigmata of tuberculous 
heredity which predisposes, according to some authors. 

Mayo 2 pointed out that in Minnesota, where surgical tuberculosis 
is rife, phthisis is uncommon, and this has been observed to be a fact 
in other places. Turban, Weicher, and King record the moie favorable 
course of phthisis where a family history of tuberculosis is present, and 
the same is the case where the individual has been scrofulous. Clive 
Riviere is inclined to attribute the scrofulous manifestations, as well 
as the surgical tuberculous lesions, to bovine infection, but he never- 
theless emphasizes their importance as immunizing factors against 
renewed infection with human bacilli. 

Experience, experimental as well as clinical, among animals has also 
not revealed any hereditary transmission of specific "predisposition" 
to the disease, despite the fact that clinical medical treatises keep on 
speaking of " predisposition" which is transmitted from generation to 
generation. Speaking of specific predisposition, Baldwin 3 says: "Here 
again the bovine race gives a negative to the assertion that tuberculous 
infection necessarily involves a transmitted weakness or susceptibility. 
On the contrary, breeding from tuberculin-reacting cows is actually 
practised as of eugenic value in preserving the best stocks. The well- 
known Bang system has been on trial long enough in Denmark to have 
demonstrated its value, and is, I believe, the approved method of pro- 
cedure in valuable dairies where tuberculosis is a serious menace." 
Harlow Brooks has shown that the progeny cf tuberculous cows show 
no excessive predisposition to the disease, as was already mentioned. 

We know that all consumptives swallow tubercle bacilli, yet tuber- 
culosis of the gastro-intestinal tract is not so frequent as opportunities 
for infection would lead us to expect. When infection of these organs 
does take place, the lesions remain local without extending to the 
regional lymphatic glands, as is the rule with primary intestinal 
tuberculosis. 

Secondary tuberculosis of the skin is exceedingly rare in consump- 
tives, although sputum reeking with tubercle bacilli is very often care- 
lessly handled by them; and when it does occur, it runs a much milder 
course than lupus — primary tuberculosis of the skin. The well-known 
"pathologist's wart" and "butcher's wart," although of a tuberculous 
character, are of no significance, apparently because of old and dor- 
mant tuberculous lesions in some other parts of the body which confer 
immunity. 

1 Lyon medical, 1910, cxv, 889. 2 Jour. Am. Med. Assn., 1905, xliv, 1156. 

3 Am. Jour. Med. Sc, 1915, cxlix, 882. 



PHTHISIS AS A MANIFESTATION OF IMMUNITY 127 

Tuberculosis on "Virgin Soil" in Human Beings.— While direct 
experiments on human beings are not available for obvious reasons, 
still some clinical facts are known which confirm the view just expressed. 
Bearing in mind that newborn infants are free from tuberculosis, no 
matter from what stock they are descended, we should expect that if 
tubercle bacilli were inoculated into infants, the resulting disease 
would run an acute and progressive course, just as is the case with 
experimental tuberculosis in guinea-pigs or rabbits. This is actually 
the case when during ritual circumcision among Jews the wound is 
infected with sputum from a tuberculous operator. (Mohel.) The 
infant promptly becomes sick with tuberculosis and the disease runs 
an acute, rapid, and fatal course, the regional lymphatic glands being 
implicated. This is a drastic contrast to the mildness of the "patholo- 
gist's wart" in the adult, which is also acquired by inoculation of 
tubercle bacilli into a wound. Woods Hutchinson 1 says that the first 
thing that struck him on visiting American Indian children's schools 
and reservations was the large number of individuals, both adults and 
children, showing huge scars in the neck or enlarged glands; next, he 
found a strong tendency among Indian children to acquire tuberculosis 
of an exceedingly rapid and fatal type. 

On the other hand, Baumgarten injected cancerous adults, who 
may be assumed to have been infected with tuberculosis during child- 
hood, with virulent bovine tubercle bacilli, and Klemperer injected 
similar microorganisms into tuberculous persons, without any dele- 
terious results (see p. 54). These authors sought to prove that bovine 
tubercle bacilli are harmless to man, but in truth they confirmed experi- 
mentally that infected individuals are immune to superinfection. In 
infants, tuberculosis, when it causes disease, appears as a general dis- 
ease similar to typhoid or septicemia; as a metastatic infection with 
deposits of tubercles in various parts of the body, like pyemia; or as 
an acute pneumonic or bronchopneumonic process, fatal in the vast 
majority of cases. The explanation for this phenomenon is that in 
the infant there occurs a primary massive infection of an organism 
that has been free heretofore from the tuberculous virus — real virgin 
soil. The same is true of primitive peoples who have never been 
infected with tubercle bacilli — when they are infected as adults, the 
disease pursues an acute and fatal course almost invariably. 

Phthisis as a Manifestation of Immunity.— From the experimental 
and clinical data arrayed here, it is clear that neither infection with 
tubercle bacilli nor predisposition is alone capable of producing phthisis. 
To each one who has become phthisical, there are many who have been 
infected with tubercle bacilli and remained healthy in the clinical sense. 
In fact, spontaneous infection acquired during childhood appears to 
render the body immune against further and renewed exogenic infec- 
tion with the same bacilli. 

i. New York Med. Jour., 1907, Ixxvi, 624. 



128 PHTHISIOGENESIS 

It is also clear that phthisis occurs only in individuals who have 
been infected with tuberculosis during childhood, but have remained 
healthy till adolescence. In other words, phthisis occurs only in persons 
who have been immunized by an earlier infection. In fact, it is in 
itself a manifestation of immunity, otherwise the patient would suc- 
cumb to acute general miliary tuberculosis, as do those who have not 
been immunized by earlier mild infection . This immunity is apparently 
sufficient to protect the individual under ordinary circumstances, 
but under certain conditions it may fail, and the person may be re- 
infected either from without, the tubercle bacilli being so ubiquitcus 
that we can hardly escape them; or from within, by the proliferation 
of the bacilli that have been harbored in "healed" or quiescent foci, 
through metastasis. 

Failure of Immunity. — Acquired immunity in contagious diseases is 
hardly ever absolute— it is only relative, sufficient for the ordinary 
conditions of life and failing during emergencies. The same appears 
to be true of the immunity acquired during childhood by infection 
with tubercle bacilli. It protects the average person against exogenic 
reinfection with tubercle bacilli, and moderate failure of immunity 
permitting reinfection does not result in general tuberculosis, but only 
in phthisis — the most vulnerable organ in the body succumbs, while 
the others are still more or less protected. 

There seems to be good evidence to the effect that the outcome of 
the infection which practically everybody passes through during 
childhood depends, in a large measure, on the extent of the microbic 
invasion. When the dose is small, immunity is the result, immaterial 
whether the initial lesion has healed completely, the bacilli being 
destroyed and the lesion cicatrized, or not. When there remain cal- 
careous foci containing virulent tubercle bacilli, they remain innocuous 
as regards their host, and are probably an even better foundation for 
immunity. But when the initial bacterial invasion is massive it may 
cause hematogenic tuberculosis of the glands, bones, or joints during 
childhood; or when the resistance is very low, fatal tuberculosis of any 
organ, especially the lungs, meninges, etc., may result. But even 
massive infection may be kept in check till adolescence when, under 
certain exciting causes, the lesion flares up again and phthisis is the result. 

Immunity through Bovine Infection. — Some authors have been 
inclined to attribute the immunity observed in most adults to infection 
during childhood with the bovine type of bacilli which protects the 
individual against superinfection with bacilli of the human type. 
Clive Riviere 1 even advocates the immunization of humanity along 
these lines. He says that "until human sources of infection can be 
practically eliminated, or artificial immunization becomes an accom- 
plished fact, infection with the bovine bacillus through the use of a 
well-mixed milk remains our best ally in the campaign against tuber- 

1 British Jour, of Tuberc, 1914, viii, 83, 



NATURE OF PREDISPOSITION TO PHTHISIS 129 

culosis." We have seen already that bovine infection is fatal only on 
exceedingly rare occasions. That it may protect against infection with 
the human type of bacillus is made highly probable by the rarity of 
phthisis in surgical tuberculosis. "Very significant in this respect also 
are the figures of McNeil for Edinburgh where, as shown by Fraser 
and Philip Mitchell, tuberculosis of bovine origin is particularly rife. 
Comparing Edinburgh with Vienna, he finds the incidence of tuberculous 
infection higher in the former for children up to the age of four years, 
and this in itself is highly suggestive of milk infection; but the valuable 
comment on this is the fact that the mortality from phthisis in Vienna 
is nearly three times as high as that for Edinburgh. Indeed, the high 
incidence of abdominal tuberculosis and the low mortality from 
phthisis are characteristic of Great Britain as a whole when compared 
with other civilized countries of Europe, and this may well bear the 
interpretation that it is the early bovine infection which protects 
against the inroads of pulmonary tuberculosis caused by the human 
strain of tubercle bacillus." 

Nature of Predisposition to Phthisis. — Obviously the evolution of 
phthisis does not depend alone on the intensity of the infection during 
childhood. The character of the soil invaded by the bacilli is perhaps 
more important. Some succumb to hematogenic tuberculosis even as 
a result of a mild infection, harmless to the average individual, which 
indicates that predisposition was a stronger factor. In what this pre- 
disposition consists we are in the dark, though some factors are known 
to reduce the natural resisting forces to a minimum. Thus, as we have 
already shown, certain occupations, especially those involving the 
inhalation of dust, prepare the soil for the proliferation of the bacilli 
by reducing the vitality of the lung locally. Perhaps shortening of the 
first rib and ossification of the first costal cartilage are instrumental in 
this direction in some persons. 

Failure of immunity may be due to various complex biochemical 
changes in the body with which we are unacquainted at the present 
state of our knowledge. This is seen in children who have been infected 
but who thrive in spite of it, until an attack of measles, whooping-cough, 
etc., which is accompanied by a failure in allergy, as is evident from 
the negative outcome of the cutaneous tuberculin test during the active 
stage of the disease, flares up the latent tuberculous focus and tuber- 
culous bronchopneumonia results. Other febrile diseases may act in the 
same manner, but we do not as yet know the exact nature and effects 
of these biochemical changes in the body following contagious disease. 

The nature of predisposition is the stumbling-block of the theories 
of phthisiogenesis. Clinical, demographic, and experimental observa- 
tions have not cleared up these important problems. It appears that 
no single predisposing factor, nor a combination of several factors, will 
fit most cases. As has been pointed out by Martius, 1 the predisposition 

1 In Brauer, Schroder, and Blumenfeld's Handbuch d. Tuberkulose, i, 395. 
9 



130 PHTHISIOGENESIS 

of the individual is, after all, not a specific entity, which is possessed 
by those who are attacked by phthisis, and lacks in those who escape 
the disease despite infection. It appears to be a complex affair: In 
each individual case there are a number of anatomical and physio- 
logical factors which may each alone, or several in combination, decide 
under certain conditions whether the person is to become phthisical, 
and even these factors are subject to great oscillations, and may com- 
bine differently under different conditions. From this point of view 
everybody is predisposed to tuberculosis, but there are many important 
differences in the resisting powers of different individual persons which 
depend on the number, intensity, and accidental combinations of the 
various predisposing factors which, by themselves, are influenced by 
certain vital, biological oscillations occurring during the lifetime of 
the individual. We thus have gradations of predisposition from the 
strongest degree of vulnerability to the highest degree of immunity. 

Endogenic and Exogenic Reinfection. — Considering phthisis as a 
disease which develops only in an organism that has been immunized 
by an earlier infection which has left a latent or " healed" tuberculous 
focus in some part of the body, the problem arises whether the flaring 
up of the local lesion in the lung is caused by a new infection from 
without, by the invasion of new bacilli, or from within by metastatic 
migration of bacilli which have been kept dormant for years until the 
immunity they conferred fails for some reason. 

Experimental findings on this point are somewhat conflicting. Orth 
and Rabinowitsch 1 have found that when guinea-pigs are mildly 
infected with small doses of mildly virulent tubercle bacilli which 
cause only local tuberculous changes, the effect produced is that a 
second infection with virulent human bacilli does not cause the usual 
generalized tuberculosis, but pulmonary tuberculosis results, bearing 
some analogy to pulmonary tuberculosis in human beings. In rabbits, 
which react to human bacilli in a manner similar to that of man, more 
than guinea-pigs, they produced in this manner chronic tuberculous 
lesions in the lungs. Hamburger, B artel, Levy, and others have 
confirmed these findings. This would indicate that phthisis is due to 
exogenic superinfection. 

That the outbreak of phthisis is due to autogenic, or metastatic, 
reinfection has been maintained by Behring, according to whom the 
primary infection takes place through the gastro-intestinal tract during 
childhood, the bacilli remaining latent till stirred into activity by some 
exciting cause. But if this was the case we should expect that pul- 
monary tuberculosis due to bovine bacilli would be very frequent, 
considering that at least 10 per cent, of infections during childhood 
are caused by this type of microorganisms. As it is, there have been 
reported very few cases of phthisis in which the bovine bacillus was 
found exclusively. It has been suggested that those infected with 

1 Drei Vortrage iiber Tuberkulose, Berlin, 1913. 



ENDOGENIC AND EXOGENIC REINFECTION 131 

bovine bacilli are immune against human bacilli, and they are the ones 
who escape phthisis despite tuberculous infection, but this would have 
to be proved. 

Romer and Much maintain that their investigations lead them to the 
conclusion that reinfection is always endogenic, or metastatic, from 
existing tuberculous foci within the body. "We knowV says Much, 1 
"that a tuberculous organism is not susceptible to, in fact it is immune 
against, superinfection from without. We must also admit that when 
an organism is infected during childhood it passes through a precarious 
crisis, but it may survive this first infection and remain endowed with 
immunity. But during adolescence, when great demands are made 
upon the vital forces, the body may be overwhelmed by the bacilli 
and the most vulnerable organ in the body — the lung — succumbs: 
thus phthisis results. One who hesitates in accepting these ideas of 
reinfection from within should only compare phthisis with syphilis." 

There are analogous conditions known in pathology showing that 
an organism may harbor virulent bacilli without any harm to itself. 
Thus, the "carriers" of typhoid, diphtheria, and other bacilli may go 
around for years without showing any symptoms of disease, although 
they are a constant danger to others. But Texas fever illustrates this 
point even better. Cattle which survive an attack remain with the 
living virus within their bodies, but are immune against new infections, 
so that they may remain in infected pastures without any danger to 
themselves. But should they suffer from any secondary derangement, 
they may, as a result, experience an acute exacerbation of the process 
owing to sudden proliferation of the virus which has been dormant for 
a long time within their bodies. 

There are similar clinical phenomena in man. It is known that 
infection with the malarial parasite protects against further infection 
with the same parasite from external sources, and for this reason the 
adult indigenous individuals in malarial districts are immune to 
malaria, as was shown by Koch. In some cases there occurs further 
infection in later years, and the result is a cachexia, a sort of malarial 
phthisis. But in such cases the initial infection must have been an 
especially strong and severe one. In syphilis this is even illustrated 
to a better advantage. Superinfections are very difficult, usually 
impossible; the integuments and mucous membranes cease to react 
to the syphilitic virus introduced from without while they are sus- 
ceptible to their action from within. John A. Fordyce, 2 in a recent 
review of this subject, cites several other examples: "Levanditi has 
demonstrated that animals suffering with spirillary infection are 
immune to a new inoculation. Their serum has a high antibody con- 
tent, but the blood still harbors parasites and is capable of producing 
a fresh infection in healthy animals. So with the serum of guinea-pigs 
inoculated with Nagana or Surra trypanosomes. This is trypanocidal 

2 Am. Jour. Med. Sc, 1915, cxlix, 761. 

1 In Brauer, Schroder, and Bhimenfeld's Handbuch d. Tuberkiilose, i, 247. 



1 32 PHTHISIOGENESIS 

for these organisms in vitro, but in vivo they have acquired an insensi- 
bility to the trypanolytic antibodies, for the blood and tissues of the 
animals still contain parasites. The same is true of human subjects 
suffering from sleeping sickness in whose serum trypanolytic, agglutin- 
ating, and other protective bodies have been demonstrated. Carrying 
the analogy to syphilis we find that an individual may harbor spiro- 
chetes for forty or fifty years, while his skin and mucous membranes 
exhibit an insusceptibility to reinoculation under natural exposure. 
However, as soon as he is freed from his infection he is again in as sus- 
ceptible a state as he was prior to his first attack." 

We have shown that healed tuberculous lesions contain living and 
virulent tubercle bacilli; in fact, even calcified foci contain them. It 
has even been questioned whether once infected with tubercle bacilli, 
the virus is ever absent from the body. And for this reason we may look 
upon phthisis as produced by endogenic reinfection. Thus, according 
to Romer, phthisis is an acute or subacute exacerbation of a latent or 
quiescent lesion in the lungs acquired by massive infection during 
childhood, the bacilli remaining dormant for years, but when the 
immunity which they conferred failed, owing to some intercurrent 
disease, the lesion in the lungs flared up. That the specific immunity 
is not altogether lacking even under these circumstances is evident 
from the fact that the lesion remains localized for a long time in the 
most vulnerable of organs — the lungs. Phthisis is thus proof of 
immunity against tuberculosis. General miliary tuberculosis cannot 
develop in an individual who has been immunized by a previous infec- 
tion with tubercle bacilli. 

The question why adults are not immunized by mild infections, as 
children are, has not been explained satisfactorily. We have already 
mentioned that adults hailing from countries where tuberculosis is 
unknown, and where they could not have been infected during child- 
hood because of the lack of tubercle bacilli, upon coming into cities 
and in contact with tubercle-laden surroundings — subjected to primary 
tuberculous infection — soon succumb to the acute forms of phthisis, 
like infants or guinea-pigs. Cobbett 1 is inclined to attribute it to the 
cessation of the strain made upon the constitution by bodily growth. 
Be that as it may, he thinks that we may conclude that infection with 
tubercle bacilli, though it does not entirely cease when adult age is 
reached, is nevertheless, like infection with most other diseases, less 
easily acquired then than in childhood and adolescence. Much 
attempted to explain it by saying that either, the organism of the child 
alone is capable of evolving a sufficient quantity of immune bodies, 
or we must assume that an adult person, coming from an environment 
free from tuberculosis to one which is tubercle-laden, freely going 
around among people among whom there are many bacilli carriers, 
is soon subjected to massive infection against which he does not possess 

1 Practitioner, 1918, c, 404. 



SUMMARY 133 

sufficient powers of resistance. On the other hand, the sheltered child 
does not roam around among various people during the first years of 
its life and comes in contact with only a few bacilli, so long as there is 
no active case of tuberculosis at home. I may add that the suggestion 
made above to the effect that the immunization of humanity during 
childhood may be accomplished by the bovine type of bacillus, which is 
not so virulent as the human type, may be responsible for this salutary 
condition. But this problem has not yet been worked out. 

Summary. — At the present state of our knowledge of tuberculous 
infection and immunity, particularly as regards chronic phthisis, the 
following conclusions appear justified : 

In civilized communities nearly all adults have been infected, though 
not all have acquired disease by virtue of this infection. 

Infection occurs in nearly all cases during childhood, the bacilli 
remaining latent within the body until some exciting cause reactivates 
them, or the natural resistance is reduced, and tuberculous disease 
results. 

Infection during childhood, so long as it is not acute and fatal imme- 
diately after the bacilli have entered the body, endows the organism 
with a heightened resistance against renewed infection with tubercle 
bacilli. The immunity thus produced is, in most persons, ample to 
protect them against exogenic or endogenic reinfection with tubercle 
bacilli during the rest of life. 

^Yhen, for any reason, this immunity fails and the bacilli within 
the body are permitted to proliferate, metastatic reinfection may occur, 
new tuberculous foci develop, and clinical phenomena of tuberculosis 
make their appearance. Experience tends to show that such metastatic 
reinfections mostly occur in individuals who were subjected to massive 
infections during childhood. 

Phthisis is thus a manifestation of immunity against exogenic and 
endogenic reinfection and superinfection with tubercle bacilli. When 
for any reason this immunity fails, no acute miliary tuberculosis 
develops, as is the case in massive primary infections, but only a local 
lesion results, the most vulnerable organ in the body — the lung — 
succumbs. 



CHAPTER VI. 
PATHOLOGY AND MORBID ANATOMY. 

THE TUBERCLE. 

Tubercle bacilli settling on susceptible soil offering suitable con- 
ditions for their growth induce a specific proliferation of the fixed 
elements of connective tissue, capillary, endothelial, and probably also 
of the epithelial cells of the air vesicles. Acting as irritants, and injur- 
ing the cells and the intercellular substances, they induce a productive 
inflammation resulting in the formation of a nodule, the specific granu- 
loma termed tubercle by Laennec. 

The tubercle is best studied in acute miliary tuberculosis, where it 
is encountered in its purest form. Throughout the lungs are scattered 
small, hard nodules. They may be gray and transparent, or yellowish- 
white and opaque. The transparent tubercles are smaller than millet 
seeds, while the opaque ones are as large, or even larger. They are 
larger and more numerous in the upper parts of the lung where they 
grow better and more rapidly. 

Microscopically, the tubercle presents a characteristic structure 
(Fig. 9). Primarily it is an avascular structure; with the growth of 
the cells, the bloodvessels and lymphatics in its neighborhood are 
compressed and obliterated. Its most peculiar characteristic is the 
large, multinuclear unit known as the giant cell. In thin sections, a 
fine network, the reticulum, is seen. The filaments are derived partly 
from extravasated fibrin, partly from curled fibrils of connective 
tissue, and partly from long, branching, interlacing processes of the 
cells, especially the giant cells, which have been described as looking 
like spider's feet, and also from newly formed connective-tissue fibrils. 

Histologically, tubercles are classified as the epithelioid and the 
round-cell varieties, depending on the predominance of either of these 
two types of cells. The peripheral cells are arranged concentrically: 
near the center they are larger, round, or oval, like epithelial nuclei. 
Scattered throughout are to be seen single lymphocytes with small, 
round nuclei and, in the typical tubercle, the polynuclear giant cell 
is located in the caseated center. While the tubercle is often round, 
it may be of any form or shape, and it usually sends out branches 
connecting it with the surrounding tissues. Most authors consider 
the round cells as lymphocytes which have wandered from the blood- 
vessels or lymphatics. 

The so-called epithelioid cells arise through the proliferation of the 
connective tissue, and especialy the endothelial cells in hematogenic 



PLATE II 




Fig. 1 




Fig. 2 



Fig. 1. — C, cavity in the pulmonary apex; F, interlobar fissure. To the 
left of the cavity are seen peribronchial nodules. Lower parts are exten- 
sively easeated. 

Fig. 2. — C, small caseous focus in the upper part of the apex; B, bronchus 
with easeated wall. The rest of the parenchyma is of normal air content, 
but anthraeotie and showing black pigmentation. (Albert Fraenkel.) 



THE TUBERCLE 135 

tuberculous follicles. They divide by karyokinesis, and fission of the 
nuclei, and because the product is similar t ) epithelial elements, it is 
called epithelioid. Such follicles are mostly of microscopic size, and 
consist mainly of this type of cell. They proliferate very slowly. 
With his theory of phagocytosis MetchnikofT, however, sees in these 
epithelioid cells derivatives of white-blood corpuscles, and inasmuch 
as they often show ameboid movements, they cannot be anything else 
than white-blood corpuscles. It has, however, been shown that these 
ameboid movements aie no conclusive proof that they are of this 
origin. 




Fig. 9. — Microscopic tubercle. (Tendeloo.) 

The Giant Cell. — The giant cell is polynuclear, with a stroma of 
fatty degenerated, or even necrotic, protoplasm. Its form and size 
are variable. It may contain as many as one hundred oval, spindle- 
shaped nuclei arranged concentrically like a crescent. The tubercle 
bacilli are mainly located in the giant cells (Fig. 9), where they may 
be seen singly or in clusters, usually at the inner side of the nuclei, or 
between the latter. They are, however, lacking in the center of the 
protoplasm of mature giant cells; probably the process of necrobiosis 
affects the bacilli as well as the body of the cell. 

The origin of the giant cells has been a debated subject. Some, like 
Weigert and Baumgarten, state that they are the results of karyo- 



136 



PATHOLOGY AND MORBID ANATOMY 



kinetic changes of the nuclei which retain their capacity for division, 
while the protoplasm, owing to the necrobiotic effect of the tubercle 
bacilli, does not divide into separate cells. In fact, it is quite common 
to find in tuberculous foci cells with degenerated protoplasm, while 
the nuclei show T an increased chromatin content. From this point of 
view the giant cell is a degenerative phenomenon. A. Guieysse- 
Pelliosier, 1 who recently made a careful study of the formation of giant 
cells in sections of tuberculous glands from experimental guinea-pigs, 
found that the giant cell is formed in an identical manner with those 
arising after the introduction of foreign bodies into tissues. The nuclei 
are derived from the absorption of nuclei, or fragments of nuclei, of 
polynuclear leukocytes by macrophages. The chromatin after absorp- 




" 





Fig. 10. — Cross-section of tuberculous bronchus. The lumen of the bronchus is 
completely filled with muddy but quite homogeneous caseous matter and the mucous 
membrane has completely vanished. The rest of the bronchial wall is very rich in cells 
aDd thickened. The thickening extends far into the neighboring alveoli. (Ribbert.) 

tion reforms a nucleus and the macrophages then become giant cells. 
The arrangement of the nuclei in a circular group is a secondary 
phenomenon, and appears only in the older giant cells. This agrees 
with the view of Metchnikoff, who sees in the giant cells one of the mani- 
festations of phagocytosis: They are macrophages, or large active 
phagocytes, produced by the fusion of many epithelial cells with the 
object of fighting the invading enemy, the tubercle bacilli, with united 
forces. The part of the giant cell which has no nuclei is usually dead, 
because of the noxious effects of the tubercle bacilli. 

Tubercle bacilli are mainly found in the giant cells, as we have 
already mentioned, and also in the epithelioid cells, while in the inter- 
cellular substance they are only rarely noted. In the caseous parts 



Compt. rend., Soc. de Biol., Paris, 1917, lxxx, 187. 



CASEATION 



137 



of the tubercle the bacilli are found at the periphery, while they are 
never seen in the center. In the caseated giant cells they are found 
only in the parts which have retained their staining property. 

Caseation. — The tuberculous follicles are avascular neoformations, 
and their vitality is not durable. No new bloodvessels are formed in 
them, as is the case with most other new growths. They are usually 
located in the alveolar framework whence they compress the neigh- 
boring alveoli and finally obliterate them, and partly in the smallest 
lymph vessels, i. e., along the walls of the smallest arterioles and 
bronchioles. In the arterioles a tuberculous obliterative endarteritis is 
formed and this alone, or in conjunction with thrombotic phenomena, 




Fig. 11. — Indurated nodule in pulmonary tuberculosis. The solid nodule has a 
dark, caseous center with irregular lacunae. It consists of coarse connective-tissue fibers 
in which carbon particles are deposited in sonie places. A giant cell is seen in the middle 
and to the right; three others are seen to the left. (Ribbert.) 



leads to occlusion of the vessel. In the small bronchioles caseous 
bronchitis may result, which may, however, arise primarily and lead 
to peribronchial tuberculosis secondarily. The bronchi become per- 
manently plugged by their own secretions and by the irritative pro- 
liferation of their epithelium. The tuberculous growth compresses and 
destroys the elastic fibers, so that in the center of the nodule there are 
only fragments of these tissues and often not even that, and air is 
completely excluded. 

The necrotic tissue is thus converted into a whitish or muddy, 
.yellowish opaque mass; dry, often fragile, at times soft, or even 
viscous in consistency. It has the appearance of dry or soft cheese. 



138 PATHOLOGY AND MORBID ANATOMY 

Microscopically, the cells are found to have undergone coagulation 
necrosis or fatty degeneration and are converted into a structureless 
mass of detritus which refuses to stain. At times, we make out between 
the remnants of the cells a filament, consisting of a fine network of 
granular fibrin, or true hyaline fibrin, the so-called "fibrinoid." Finally, 
a stage is reached when the debris of cells and fibrin become a homo- 
geneous mass in which no structure is seen at all. This is true caseous 
matter. 

Some have suggested that tuberculous toxins are specifically effec- 
tive in causing necrobiosis of the affected cells, but this has not been 
proved. It must be emphasized that desquamation of epithelial cells, 
necrosis, and caseation are not specific tuberculous changes. They 
are found also in various degrees of intensity in several other inflam- 
matory processes in the lungs. Necrosis, especially coagulation necro- 
sis, is also found in diphtheritic inflammation of mucous membrane, 
and caseation in gummatous changes. The caseous gummatous nodule 
can hardly be differentiated from the tuberculous. 

Calcification. — The caseous matter may become surrounded by a 
layer of connective tissue — encapsulated — and then, by the exclusion 
of water, it becomes inspissated and much reduced in size. In time 
small granules of calcium are gradually deposited until it becomes 
altogether calcified. Small calcified granules may coalesce into larger 
concretions, until finally they are converted into a dry, solid, jagged, 
or fragile concretion which looks very much like chalk. These concre- 
tions often contain virulent bacilli. In general, it can be stated that 
it is never dissolved or absorbed by autolysis, as is the case with other 
dead matter in the tissues. But caseous matter may be gradually per- 
meated by fibrinous tissue and finally converted into a solid fibrous 
scar. 

Softening. — Very often the tubercle, instead of calcifying or under- 
going fibrosis, softens as a result of the action of proteolytic enzymes 
with which we are yet unacquainted. In this case there develops a 
puriform, thin liquid, without any pus cells but containing bits of 
cheesy matter, which is known as puriform liquefaction and "tuber- 
culous pus." In other cases real pus is formed, or a mixture of both 
liquids, which is also known as tuberculous pus. 

Sclerosis. — But the tubercle is not always destined to necrosis, 
caseous degeneration, calcification, or liquefaction. In most cases in 
which phthisis does not develop at all, or is checked in its progress 
and healing finally results, the cells of the tuberculous nodule are 
converted into fibrous scar tissue through the agency of the proliferat- 
ing connective-tissue cells. These connective-tissue cells are derived 
from two sources: From the cells in the neighborhood of the tubercle, 
and from the tubercle itself. While making autopsies on persons who 
died from any cause pathologists have found that a large proportion 
have scars in their lungs and pleura, thus showing that an enormous 
number of persons have had tuberculosis which healed spontaneously. 



TUBERCLES OF THE LUNG 139 

These healed or dormant lesions are responsible for the large number 
of persons obviously non-tuberculous, yet responding to the tuberculin 
test. 

The fate of the tubercle depends on the intensity of the two processes 
of connective-tissue proliferation or sclerosis, and of caseation. In 
fact, the clinical course of the disease is mainly influenced by their 
relative intensity, the former being reparative, and the latter destruc- 
tive. If the exudative process predominates and progresses with 
rapidity, the tuberculous focus increases in size and clinical signifi- 
cance; but when the proliferative process predominates, the inflam- 
mation proceeds slowly, and may even terminate in a cure through 
sclerosis. In chronic phthisis the two processes usually go hand-in- 
hand; the reparative, manifesting itself by the proliferation of con- 
nective-tissue cells, is seen at the periphery of the tubercle, while the 
center caseates. Pathologists then speak of fibrocaseous phthisis. In 
conglomerate tubercles the central foci may caseate, while those at 
the periphery are healing by sclerosis, and. thus surround the lesion 
and prevent its progress by encapsulation of the cheesy center which 
finally calcifies, as was already shown. 

Tubercles in the Lung. — Gross Appearances. — In the vast majority 
of cases the tuberculous lung is found at autopsy to be adherent to 
the inner surface of the thoracic wall, at least the affected apex is found 
densely adherent. Very frequently the pleural sheets are so thick and 
dense that the lung cannot be removed from the thorax with ease, but 
must be torn forcibly, or cut away. In some cases the entire pleura is 
thick, and the pleural cavity is completely obliterated. The apical 
and diaphragmatic pleural sheets are, however, the parts most often 
thus affected. 

The external appearance of the affected lobe in chronic phthisis is 
irregular, deformed, or puckered, and of comparatively solid consis- 
tency. Frequently the surface of the lung is found studded with small 
pleural or subpleural tuberculous nodules; the interlobar fissure below 
the lobe in which the main lesion is located is usually obliterated by 
adhesions. The intrathoracic lymphatic glands, the hilus, mediastinal, 
and tracheobronchial are enlarged, hard and often dark because of 
anthracosis. On section these glands may be found in various forms 
of tuberculous degeneration, caseous, fibroid, or calcified'. The first 
foci usually take root in the neighborhood of the apices and may 
remain there exclusively for a long time; in progressive cases, they 
extend by the production of new nodules. They usually consist in a 
combination of both the productive inflammation in the form of nodu- 
lar formation and a pneumonic process. The first tubercles occur 
as single and isolated nodules, or groups around the bronchi and 
the bronchioles, and at times also around the walls of the larger 
bronchi and the bloodvessels — peribronchial and perivascular tuber- 
cles. Varying with the intensity of the affection and the resistance of 
the individual, the nodules enlarge and extend slowly or rapidly and 



140 PATHOLOGY AND MORBID ANATOMY 

new ones appear around them. Large conglomerations of tubercles 
may thus be formed. In progressive cases the tubercles do not remain 
separated for a long time, but by fusion of many the focus enlarges 
and extends. The central nodules sooner or later begin to disintegrate 
and are converted into caseous matter. But in most cases a sclerotic 
process may be detected which limits its progress, excepting in the very 
acute types of the disease. 

On section the gross appearance of the typical tuberculous lesion in 
the lung presents a very variegated picture. In fact, there are hardly 
two cases which look alike. The scar tissue surrounding the cheesy 
centers, or insinuating itself within many caseous and softened areas, 
is a very strong substance made up of thick fibers and can be recog- 
nized by its color. It is dark because particles of carbon derived 
from the inspired air are deposited in it, and they cannot be expelled 
by expectoration because of their inability to reach the bronchial 
glands owing to the fact that the lymph channels are occluded or 
obliterated. It is therefore more or less dark gray, or even black in 
color, which contrasts distinctly from the various other colors of the 
lungs. The distribution of scar tissue is variable. In some cases it is 
mainly in the center of a group of tubercles, or it surrounds the caseated 
masses with extensive processes. A black, round or radiating scar may 
enclose a nodule the size of a pea or even larger, or several nodules. 
The cheesy matter is dry, and when old, calcified. This is very often 
found at the apex of clinically healed pulmonary tuberculosis. 

Later the caseous matter softens and, when the degenerative process 
extends, reaching and implicating the bronchial mucous membrane, 
the softened debris may break through the alveoli or the bronchi. 
But in most cases sclerosis prevents the spread of the lesion, and even 
encapsulates it with a more or less dense fibrous shell. Within the 
capsule the caseous matter dries up and finally calcifies, and it is stated 
that small foci may even be absorbed, though this is doubtful. 

There has been quite some discussion as to the origin of ulcerations 
on the surface of the bronchial mucous membrane and in the paren- 
chyma of the lung. Some have considered these as the points at which 
the infecting bacilli have entered with the inspired air and set up 
the disease; that these ulcerations represent the primary tuberculous 
lesion. As far back as 1876 Parrot pointed out that in all cases of 
tracheobronchial adenitis such a primary lesion may be found in the 
lung if carefully searched for. This is known among French patholo- 
gists as la hi de Parrot, Parrot's law. G. Kuss 1 has confirmed Parrot's 
findings on extensive autopsy material, and more recently Anton 
Ghon 2 has found the same condition while making numerous autopsies. 
French authors refer to these primary lesions as chancres tubercuku.v, 
and the enlarged regional glands which are almost invariably found, 
as bubons d'emblee. 

1 De heredite par asit aire de la tuber culose humaine, Paris, 1898. 

2 Der primare Lungenherd bei der Tuberkulose der Kinder, Berlin, 1912. 



CASEOUS PNEUMONIA 141 

Others maintain that there are many cases of tracheobronchial 
adenopathy in which such a primary lesion in the bronchioles or 
pulmonary parenchyma cannot be discovered at the autopsy. It 
is also shown that even when found it should not be concluded in all 
cases that this ulceration represents the point of entry of the bacilli. 
They may be due to extension of the peribronchial nodules which, 
when enlarging, have reached the mucous membrane, caseated it 
and produced ulceration. As was already stated in Chapter V, the 
problem whether phthisis is of hematogenic or bronchogenic origin 
rotates around this point, to a large extent. The experiments of Bac- 
meister have shown conclusively that such lesions may be produced 
by the hematogenic route, and that the primary lesion is not commonly 
in the mucous membrane. But this does not exclude infection of the 
mucous membrane. We have already, shown that the bacilli may be 
deposited on the bronchial mucous membrane and pass through the 
lymph channels into the subepithelial tissue where they take root, 
without producing a lesion at the point of entry. 

Caseous Pneumonia. — The nodular formations are not the only 
changes wrought by the tubercle bacilli in the lungs. There are also 
seen larger primary infiltrations which are pneumonic in character; 
in fact, these distinguish phthisis from pure tuberculosis. .These areas 
are of variable size, from that of a pea to that of an egg, or even 
larger. They are round, oval, leaf-shaped or lobular in arrangement; 
they may be single, or several may be found clustered together. They 
are pale, grayish and, later, muddy in color; at times they look like 
cheese. They are found in rapidly progressing fibrinous exudations 
which caseate quickly — caseous pneumonia. Real lobar caseous pneu- 
monia is exceedingly rare. The diseased parts are voluminous, airless, 
heavy, like in the hepatization of lobar pneumonia. 

Microscopically, there is found an albuminous mass in which fibrin, 
red-blood corpuscles and alveolar epithelium may be discovered, but 
the alveolar structure may still be made out at an early stage. When 
seen in the early stage we can follow the rapidly ensuing process of 
coagulation necrosis in the alveolar septae. Tubercle bacilli are found 
in large numbers, especially at the periphery of the cheesy focus. 
The final result is always expulsion of the caseated and degenerated 
debris, leaving excavations, which will be discussed later on, excepting 
when the process involves but a very small area, and some authors 
say that a cure is then possible by absorption of the caseous 
matter. 

Caseous pneumonia cannot always be differentiated from nodular 
tuberculous lesions, because when the nodules extend rapidly, as they 
do in some acute cases, they consist mainly of a conglomerate group 
of alveoli filled with exudate; the more rapidly the process progresses, 
the more they are coalescing and the greater the similarity to caseous 
pneumonia. 



142 PATHOLOGY AND MORBID ANATOMY 

Beitzke 1 points out the main differences between tubercle and case- 
ous pneumonia as follows: Caseous pneumonia is an exudative inflam- 
mation, while tubercle is a productive one. In the former there are 
therefore found loose exudate cells and fibrin, while in the latter solid 
tissue is found, and fibrin is almost never encountered. The exudate 
in caseous pneumonia lies in the lumen of the alveoli, while the tubercle 
is located in the interstitial tissues. In caseous pneumonia the elastic 
fibers remain intact, while the granulation tissue of the tubercle 
destroys them. These differences show the necessity for differentia- 
tion between the two processes. But etiologically they cannot be sepa- 
rated: Both are due to the same cause, both combine and affect the 
lung tissue, so that only the microscope can decide the intensity with 
which each is represented in a given lesion. 

Localization and Fate of the First Lesion in the Lung. — The first 
lesion cannot be recognized at autopsies of cases on old chronic tuber- 
culosis, and it cannot be definitely determined whether the disease 
has arisen by the hematogenic or aerogenic route, as has already been 
mentioned. It appears, however, that the initial lesion heals in the 
vast majority of cases. It may also happen that the initial lesion 
should be completely, or partly, healed in one lung, while the second 
lung becomes affected with progressive disease. The nodules undergo 
complete fibrous degeneration, become surrounded by connective tissue 
which often implicates the surrounding overlying pleura, a cicatrb 
is formed which contracts the affected part of the lung, resulting in 
those puckered scars so often seen at autopsies. Inasmuch as the 
lymph channels are obliterated, the pigment particles inhaled with 
the inspired air cannot be removed, and they remain in the connective 
tissue, thus causing slaty induration. 

This mode of healing is not the rule. Often the focus caseates and 
is surrounded by a fibrous capsule; the caseous center then softens, 
as has already been described. 

Extension of the Lesion. — The morbid focus may erode a blood- 
vessel and thus break into the circulation, causing acute general miliary 
tuberculosis, but this is comparatively rare, perhaps because of throm- 
bosis of the supplying vessels. Usually the process extends by the 
invasion of the tissues in the immediate neighborhood of the initial 
tubercle. Even when some sclerosis takes place, or the old tubercles 
calcify, the extension may proceed unabated. Conglomerate tubercles, 
massive infiltrations which are complicated by pneumonic processes are 
thus evolved. 

The bacilli spread along the lymph spaces and lymph channels from 
the areas which have undergone pneumonic changes. This is proved 
by the fact that around old lesions there is often found a crop of 
new tubercles. In the same manner occur fresh lesions in the neigh- 
borhood of old scars or calcified areas in the apex. Formerly it was 

1 In Aschoff's Spez. pathol. Anatomie, Berlin, 1913, ii, 299. 



EXTENSION OF THE LESION 



143 



thought that the latter are caused by new infections, or superinfec- 
tions, but since we have learned about the immunity of the tuberculous 
to new exogenic tuberculous infections, we consider these as metas- 
tatic endogenic extensions of the process. These metastatic tubercles 
increase in number, coalesce, and finally caseate. 

At times the extension of the process proceeds along the peribron- 
chial lymph channels and the result is a lobular arrangement of the 
focus, often looking like a mulberry. Some of these lesions, especially 
when exudation takes place, simulate the bronchopneumonic picture 
very much. 

a 




Fig. 12. — Tuberculous cavity (a) at apex of lung, showing its relation to a bronchus. 

(Adami and McCrae.) 

Metastatic extension of the process may also occur along the bron- 
chial tubes and then it runs a rather acute and progressive course. 
When a necrosed focus reaches the inner surface of a larger bronchus 
and breaks through the mucous membrane, the caseated matter is 
carried along the lumen of the tube and may be coughed out. But at 
times it is aspirated into the alveoli where it may produce a lesion 
similar to that of the primary infection. Inasmuch as in such cases 
we deal with larger numbers of bacilli, they may be distributed over 
larger areas. Most of these aspiration infections occur in the lower 
lobes of the lungs, but the metastatic infective matter may be carried 
to the apex by vigorous cough. These metastatic auto-infections may 
produce disseminated tuberculosis, but in the majority of cases a single 
area is infected and the lesion extends by contiguity, or is of the 
caseous pneumonic variety; in others indurated nodules result. 

Dr. J. Kingston Fowler 1 has given in detail an account of the usual 
course of the secondary deposits in chronic or subacute phthisis as he 
found it while making numerous autopsies. He found that the first 
deposit of tubercles is not at the extreme apex. It is most commonly 

1 The Localization of the Lesions of Phthisis, London, 1888. 



144 PATHOLOGY AND MORBID ANATOMY 

situated from an inch to an inch and a half below the summit of the 
lung and rather nearer to the posterior and external borders, and 
spreads backward, this line of extension explaining the fact that the 
physical signs of tubercle are often first noticed over the supraspinous 
fossa. In front, the lesion corresponds to the supraclavicular fossa 
or to a spot just below the center of the upper lobe, about three- 
quarters of an inch within its- margin, and perhaps separated by an 
inch or more of healthv tissue. The second and less usual seat of the 



,;/ V 



^m. 



Fig. 13. — Wall of a pulmonary cavity. The upper part of the section shows tissue 
undergoing caseous degeneration, in which may be noted the following points : leuko- 
cytes whose nuclei have, at least in part, retained their staining properties; an obliter- 
ated vessel, some of the elastic tissue of which still persists;* finally, a pulmonary arteriole 
almost blocked by endarteritis, the upper part of the vessel being included in the caseous 
coat of the cavity and in the process of tuberculous necrobiosis. (Letulle and Nattan- 
Larrier.) 

primary lesion is somewhat lower and more external, and corresponds 
to the first and second interspaces at the outer third of the clavicle. 
The lesion extends downward. The part wdiich next shows tubercular 
deposit is the apex of the lower lobe (the middle right lobe being passed 
over) , from an inch to an inch and a half below the upper and posterior 
extremity, and about the same distance from the posterior border, 
a spot nearly corresponding to the chest wall opposite the fifth dorsal 
spine, midway between the scapular border and the spinous processes. 
This lesion tends to spread backward toward the posterior border of 



PLATE III 




Large Irregular Cavity with Shaggy Walls in Upper Lobe, 
which is Covered with a Thick Pleura. 

Lower lobe shows conglomerate tubercles and gelatinous degeneration. 
Anthraeosis all over. 



PLATE IV 




Four Large Communicating Cavities, with Smooth, Glistening 
Walls and Crossed by Vascular Bridges. Pleura Very Much 
Thickened. 



PLATE V 




Enormous Excavation of Nearly the Whole Lung. 

'he wall is smooth, but traversed by thick bridges. Bronchial glands 
enlarged and calcified. 



PLATE V 




Caseous Pneumonia in Upper Lobe. 

Bronchi widely dilated. Miliary tubercles in lower lobe, Enlarged bronchia: 
glands. Pleura thick and covered with miliary tubercles. 



EXTENSION OF THE LESION 



145 



the lung, and laterally along the interlobar septum. The extension 
in the lower lobe is almost always from above downward and by 
islands of deposit of racemose shape with healthy lung between. The 
second lung is seldom the seat of secondary deposits until the lower 
lobe of the first lung attacked is implicated. The lesions are usually 






















C 



l i'V 




y— 1 



Fig. 14. — Large subpleural pulmonary cavity, pi, thickened visceral pleura; p, sub- 
pleural pulmonary parenchyma transformed into fibrous tissue; /, groups of leukocytes 
accumulated under the visceral pleura; si, fibrous tissue under caseous masses which 
delimit the wall of the cavity; s, caseous masses formed at the expense of the pulmonary 
parenchyma and representing the zone of extension of the cavitary lesion; v, v, pulmonary 
vein placed in the center of projections which partition the cavity (remains of the inter- 
lobar framework) ; I, purulent masses loaded with bacilli attached to the surface of the 
cavity; a, pulmonary parenchyma not yet invaded by tuberculous caseation. (Letulle 
and Nattan-Larrier.) 



located in the same situations to those of the apex of the opposite side, 
but sometimes their site is close to the interlobar septum, midway 
between its upper and lower extremities, corresponding to the upper 
axillary fold. Extension in the lower lobe of the second lung follows 
the course of the lesions in the lower lobe of the first lung. 
10 



146 PATHOLOGY AND MORBID ANATOMY 

Emphysema. — The unaffected parts of the lung in chronic phthisis 
often show emphysematous changes; in fact, occasionally on remov- 
ing the lungs from the thorax after death, they may be found so 
voluminous that the tuberculous lesion is not seen without a search. 
The surface of the emphysematous parts of the lung is usually puck- 
ered because of the traction exerted by fibrous bands and excava- 
tions within the organ; or, in -localized emphysema, which is more 
frequent, the surface shows bulla? of various sizes. 

This emphysema is compensatory. When one lung is extensively 
involved by the tuberculous process, the other undergoes vicarious 
enlargement, at times encroaching beyond the middle line; when both 
lungs are affected, the unaffected parts become emphysematous. It 
appears that this is strictly for the purpose of enlarging the alveolar 
surface of the parts which remain intact and thus increasing the 
breathing surface. In fact, microscopic examination of the emphyse- 
matous parts of the lung shows that there is no degenerative atrophy 
of the alveolar septse and bloodvessels, as in true emphysema. The 
alveoli are simply distended. 

Cavitation. — When the caseated and softened detritus, affected by 
certain chemical changes, becomes undermined in various directions, 
blocks of dense tissue are loosened and cast off, then expectorated, 
leaving vacant areas in the lungs which communicate with one or more 
bronchi. The walls may appear sinous, pouchy and covered with 
caseous or purulent material and detritus of disintegrated tissues, or 
covered with a pyogenic membrane. In some cases they are smooth 
and glittering, all of which depends on their mode of origin. 

The excavations in phthisis may be single or multiple and they are 
mostly located in the upper parts of the lungs, the apices. They may 
be the size of a hemp seed to that of a fist, and in rare cases the com- 
plete lung is excavated, leaving a thick shell of the pleura. William 
Ewart 1 pointed out that excavation is especially prone to attack defi- 
nite regions of the lungs. The apex of the lower lobe is thus affected 
at a date anterior to the implication of the lower parts of the upper 
lobe. The base and anterior border of the lower lobe are least prone 
to excavation, just as these parts are altogether the last to be involved 
in the tuberculous process. 

The question whether true bronchiedatic cavities may occur in 
phthisis has been debated. Ewart denied such a possibility, and when 
found, he considers it purely secondary to the undue strain thrown 
upon the spongy structures which escaped disease. But more recent 
investigations have shown that they may occur. Delafield and Prudden 
found them very frequently. The superficial layer of an affected 
bronchus may be cast off while the process of caseation goes on in the 
deeper layers. In fact, cavities may be formed without the destruc- 
tion of the inner bronchial lining. When the tuberculous process pro- 

1 British Med. Jour., 1882. 



CAVITATION 147 

ceeds slowly and proliferation of tissue is more active than necrosis, 
the bronchi dilate cylindrically and, because the more resisting ele- 
ments — cartilage, elastic fibers, and muscles — perish, only an unsup- 
ported, smooth or slightly ulcerated mucous membrane remains, which 
yields to the expiratory pressure of the air during cough. These exca- 
vations are usually cylindrical or round in shape. They may be 
considered true bronchiectatic cavities. 

When multiple, the separating walls of cavities may be gradually 
destroyed and a sinous vomica is thus formed. The large vessels and 
the affected bronchi resist the destructive process for a long time 
and remain as cylindrical trabecular, traversing the cavity in various 
directions. These tough septse and bridles are, however, not always 
remnants of persisting bronchi and bloodvessels. William Ewart has 
shown that they are more often chiefly composed of condensed airless 
lung, representing the remains of collapsed alveolar tissue originally 
separating discrete cavities. When finally these are also destroyed, 
only ridges and stumps of fibrous tissue remain within the cavity, 
and also septse which separate accessory excavations communicating 
with the main cavity. 

Only a small proportion of the cavities are bronchiectatic in origin; 
the vast majority arise through the caseation and hepatization of pul- 
monary parenchyma and expulsion of the necrotic tissue by expectora- 
tion. They have irregular, ragged walls on which there are attached 
pieces of necrotic tissue of various dimensions, bands separating rem- 
nants of interlobular septse of the lung. Within the cavity there are 
often found some large necrotic lumps of tissue, or sequestra, which are 
too large to be expelled through the communicating bronchus. On rare 
occasions a cavity is formed when a large part of caseated pulmonary 
parenchyma is sequestrated in toto. In case the cavity is derived 
from a small caseous peribronchial or bronchopneumonic focus, it is 
small, more or less circumscribed and round. But when it is derived 
from a larger pneumonic process it is large from the start and irregu- 
larly limited. But small excavations may fuse, coalesce, and form 
large, pouchy cavities. The septse which separate them fade away and 
a large, ragged excavation is formed; its walls are covered with a 
pyogenic membrane, consisting of granulation tissue and secreting 
tuberculous pus, like a chronic abscess. 

William Ewart thus describes the walls of tuberculous cavities 
which have been freed from secretions and debris: Internally the 
surface is lined with a grayish false membrane, often of appreciable 
thickness, but in other cases possessing a little more substance than 
the bloom of a fresh fruit. In either case it is readily detached and 
exposes a layer which constitutes the inner and vascular portion of the 
capsule, the outer portion of which is purely fibrous. The relative 
thickness of these three coats varies according to the age of the cavities 
and to the degree of irritation under which they may be placed. The 
chief features of tuberculous cavities are: (1) Absence of protecting 



148 PATHOLOGY AND MORBID ANATOMY 

epithelium; (2) gradual decay, leading to the formation of a necrotic 
layer (pseudomembrane) ; (3) gradual fibroid growth from without 
constituting the so-called capsule. 

Formerly it was stated that cavitation invariably implies mixed 
infection. T. Mitchell Prudden's 1 experimental investigations have 
shown that injections of pure cultures of tubercle bacilli into the trachea 
of guinea-pigs and rabbits produced pulmonary infiltrations; when 
streptococci were added, cavitation was produced. But more recent 
investigations tend to show that tubercle bacilli alone are capable of 
producing excavations. In this country Ira Aver 2 found cavities in 
the lungs of rabbits after injecting intratracheally massive doses of 
suspension of tubercle bacilli containing many coarse clumps. Bac- 
meister's experiments also showed that in animals in which tuberculous 
infection produces no cavitation, pressure on the apex will produce it, 
and that mixed infection is not necessary for the purpose. The pyo- 
genic microorganisms found in the walls and secretions of tuberculous 
cavities are now explained as secondary implantations of these organ- 
isms after cavitation has taken place as a result of the action of the 
tubercle bacilli. 

In slowly progressing or stationary cases a wall of connective 
tissue, even of non-tuberculous granulation tissue, may form around the 
excavation, and the necrotic parts within are cast off and expectorated, 
leaving a smooth cavity. On the other hand, in progressive cases, 
the necrotic process digs itself deeper and deeper into the paren- 
chyma and the cavity keeps on enlarging and may attain extensive 
dimensions. With this process, non-tuberculous infection often takes 
place through the invasion of streptococci and staphylococci and other 
microorganisms which invade the walls. Here mixed infection is 
frequently very effective in extending the diseased area. The pleural 
layers over superficially located cavities are usually united by dense 
adhesions. 

These cavities have a tendency to enlarge in the manner just 
described, but on rare occasions they may shrink because of vigorous 
sclerosis around the lesion which causes contraction. It is more 
common that the walls should remain smooth and quiescent for 
many years and, like a chronic abscess, discharge externally through 
a narrow sinus. But even caseous, ragged cavities may expel the 
necrotic tissue completely and permit the proliferation of connective 
tissue around the walls. Healing may thus result, the spongy con- 
dition of the adjacent lung favoring contraction. But such a course 
is less likely to occur when the excavation is extensive, owing to 
the surrounding caseous pneumonic processes which usually show a 
tendency to progressive decay. 

In extreme cases in which the excavations are extensive and the 
formation of connective tissue is vigorous, implicating the subpleural 

1 New York Med. Jour., 1894, lx, 1. 

2 Jour. Med. Research, 1914, xxv, 141. 



PLATE VII 




oluminous Tuberculous Lung with Large Cavity Communicating 

with Main Bronchus. 

Bronchiectasis. Hilus gJand enlarged. Lower lobe studded with miliary and 

softened tubercles. 



ANEURYSMS OF RASMUSSEN 149 

structures, the entire lung may be destroyed and reduced to the size 
of a man's fist. In these cases the diaphragm is pulled upward and 
with it some of the abdominal viscera, especially the liver and stomach. 
The mediastinum is pulled over to the affected side, pushed along 
by the unaffected emphysematous lung. Complete dextrocardia may 
be found in such cases, with the tuberculous lesion in the right lung; 
in left-sided lesions the heart is often pulled to the left and upward. 
Closed Cavities. — Occasionally cavities are found in the pulmonary 
parenchyma which do not communicate directly with a bronchus, 
either because the lumen is occluded with the products of the exudate, 
or connective tissue has proliferated just at that point and plugged 
up the passage to the bronchus. Such a closed cavity may open up 
secondarily when the plug is removed from any cause. Perfectly closed 
cavities in the anatomical sense are not frequently encountered by 
pathologists, at any rate not so frequently as clinicians make such a 
diagnosis. 








£ 



Fig. 15. — Aneurysm of Rasmussen. The cavity is cut at two points and shows the 
waU (c) with a cavitary projection (a), the aneurysm, which is ruptured above. The 
blood has coagulated in the lower part of the aneurysmal sac. The wall of the cavity has 
a caseous lining which is continued into the aneurysm. Several pulmonary veins (p), 
included in the caseous lining, have been obliterated and can only be recognized by the 
remaiDs of the elastic fibers. (Letulle and Nattan-Larrier.) 

Aneurysms of Rasmussen. — When the process of caseation and 
softening involves one of the bloodvessels, which very often traverse 
the walls of cavities, ulceration may extend to the vessel, causing pro- 



150 PATHOLOGY AND MORBID ANATOMY 

fuse and fatal hemorrhage. The walls of the exposed vessel become 
thinner and thinner and finally erode. Because of the loss of support 
due to the progressive inflammatory decay of the surrounding pul- 
monary parenchyma, it finally yields to the intra-arterial blood- pressure. 

More frequently hemorrhage occurs after the formation of an 
aneurysmal dilation of some branches of the pulmonary artery travers- 
ing the walls of the cavity (Fig. 15), first described by Rasmussen. 
The diseased arterial wall yields to the pressure, gives in first without 
rupturing owing to the w T ithdraw r al of support of the exposed side, 
and a sacculated aneurysm results; rarely a fusiform aneurysm results 
from the uniform dilation of the artery. Douglas Powell points out 
that the fibrotic cavities of old standing are more likely to develop 
aneurysm, and that aneurysm is more especially found on the exposed 
side of vessels which are partly buried in indurated tissue. It is diffi- 
cult to discern these aneurysms in most cases which come to autopsy 
because the cavities in which they are located are flooded with blood. 
Only after thoroughly washing the cavity may they be detected as 
white, round, sessile projections from the caseous w 7 all of the excava- 
tion. They vary in size from that of a pinhead to that of a pea. 
Exceptionally they are of the size of a plum. They are usually single, 
but there may be found more than one and, in rare cases, more than 
twenty have been found in one lung. In exceptional cases healed 
aneurysms of Rasmussen have been found in the tuberculous cavities. 

Because organized clots and thrombi obliterate the vessel, hemor- 
rhage is comparatively rare unless these aneurysms form. In small 
cavities the effused blood may by itself prevent further hemorrhage, 
providing the communicating bronchus is temporarily plugged, or is 
naturally of a narrow caliber. But many cavities are large and when a 
vessel ruptures, hemorrhage of great violence takes place. 

Rupture of a Cavity into the Pleura. — When a rapidly progressing 
-excavation is located superficially in the lung and reaches the surface, 
the pleura may caseate and rupture. In acute cases in which there 
is no time for the formation of adhesions between the pleural layers, 
a loss of continuity in the latter opens up a cavity and permits the 
escape of its contents, as w T ell as air, into the pleural cavity. Pneumo- 
thorax is the result, and when this has lasted for some time, serous 
and purulent effusions — hydropneumothorax, pyopneumothorax, etc., 
are formed. These are quite rare in slowly progressing cases of 
phthisis because adhesive pleurisy results before rupture of an 
excavation takes place. In old cases I have observed that when 
pneumothorax does occur the rupture usually takes place into the 
pleura of the side that was only recently implicated. 

Reparative Processes. — We have already spoken of the process of 
repair that goes on hand-in-hand with the process of destruction in 
phthisis, and which is found to a certain degree in all cases excepting 
those of the most acute types. Judging by the large proportions of 
persons who at the autopsy are found with fibrous scars in the lungs 



REPARATIVE PROCESSES 151 

and pleura, as well as with calcified foci in the parenchyma and glands, 
it becomes a convincing fact that more tuberculous lesions in the lungs 
are healed than progress to caseation and softening. It has also been 
found that many cases of these "healed" tubercles coutain virulent 
tubercle bacilli and thus remain a constant source of danger: They 
may flare up at any time and again begin to activate, or by metastasis 
create new tuberculous foci in adjacent or distant parts of the lungs 
or other organs. 

Tendeloo 1 gives the following details about the reparative processes 
in pulmonary tuberculosis: 

1. Every fibrous focus is to be considered as an old tuberculous lesion. 

2. Calcification removes all danger of the further spread of the 
lesion. (This is not in agreement with the views expressed above and 
which are accepted by most authors.) 

3. A fibrous capsule separates quite effectively its caseous contents 
from the rest of the parenchyma of the lung, and the process may 
remain quiescent for a long time. So long as there remains caseous 
matter within the capsule, or non-fibrous tuberculous tissue, there is 
always danger that the caseous focus may extend beyond the fibrous 
capsule, and also that the decay of the latter may favor a further exteu- 
sion of the tuberculous process by growth and metastasis. So long as 
the bacilli remain virulent in the lesion, and there are connections 
between the contents of the focus and the surrounding pulmonary 
parenchyma through lymph spaces, they can grow imder certain 
circum stances and induce pathological changes in other parts of the 
lung. On the other hand, a fibrous capsule interferes with medication 
reaching the lesion. 

4. A fibrous capsule has the same significance for an excavation. 
But in this case other dangers are added: So long as the cavities 
contain caseous matter, bronchogenic metastasis is threatening because 
there are always virulent bacilli in the caseous matter. The dangers 
of softening are greater in excavations communicating with the bronchi 
because the air has free access to their contents and may bring in other 
microorganisms, thus causing mixed infections. 

5. Healing of a cavity is possible when it is cleared of its contents 
and the walls granulate. Small vomica? may heal when their contents 
are evacuated and the walls shrink. In more extensive excavations 
there always remains some vacant space. When no open lesion remains, 
the elastic fibers and bacilli disappear from the sputum. 

Ewart points out that whereas in other organs the obliteration of 
abnormal spaces is effected by free granulations arising from the 
bottom of the cavity, surface granulations are practically absent 
from tuberculous excavations. Still, he holds that, if freely drained, 
they may granulate successfully and the walls finally adhere. This is 
in agreement with the more recent views of Tendeloo. But this is 

1 In Brauer, Schroder, and Blumenfeld's Handbuch der Tuberkulose, 1915, i, 98. 



152 PATHOLOGY AND MORBID ANATOMY 

more likely to be seen in small vomicae, while in the large ones the air 
and fluid contents offer obstacles to perfect contact of the surfaces. 

In general, we may consider the productive tissue changes as salu- 
tary, while the degenerative — caseation and softening — as phenomena 
lurking with dangers. Still, even in the latter healing is possible 
through calcification, or the removal of the products of tissue disinte- 
gration from the air passages. It is doubtful whether caseous matter 




Fig. 16. — Primary caseous focus in the left upper lobe with miliary tubercles in its 
vicinity. Caseation of the regional lymph nodes of the left upper lobe. Caseation of 
the upper tracheobronchial lymph nodes. Acute miliary tubercles in the lower tracheo- 
bronchial lymph nodes. Over both lungs disseminated tubercles are to be seen. The 
upper tracheobronchial and bronchopulmonary lymph nodes in the right side are free 
from pathological changes. (Anton Ghon.) 

can be absorbed, though some insist that this is possible. Exudative 
tuberculosis may terminate favorably or unfavorably, according to 
its progress along the lines of absorption, or in other forms, caseation 
and softening, and elimination with the expectoration or by calcifi- 
cation . 

It thus appears that even extensive tuberculosis may become quies- 
cent, although we cannot speak of healing and restitutio ad integrum 



PLATE VIII 



J: '•^f^f 










«T* 



\ 






^s 



Acute Progressive Phthisis. 

Patient succumbed to a brisk pulmonary hemorrhage. Lung honey- 
combed -with cavities; very large cavity in upper lobe. Most of the 
smaller cavities, as well as the communicating bronchus, are filled with 
clotted blood. Hilus glands enlarged and caseous. Pleura thick and 
adherent. 



EXTRATH0RAC1C PATHOLOGICAL CHANGES 153 

in the anatomical sense. It must always be borne in mind in this 
connection that the anatomical changes are not the only ones which 
decide the outcome of the disease in most cases. 

Pathological Changes in Other Organs.— The glands, especially 
those in the thorax — the bronchial, tracheal, and mediastinal — and 
of the mesentery are very often affected in children and adults who 
suffer from phthisis, more often than is generally appreciated. In 
fact, it may be stated that the tracheobronchial glands are affected 
in nearly every case of phthisis. On careful and painstaking search 
small, microscopic tuberculous foci are often found in apparently 
unaffected glands; but the majority are swollen, enlarged and many 
are softened while others are calcified. In children these tuberculous 
glands very often give no clinical indication of their implication; in 
fact, it is at times difficult to discover any changes in the bronchi 
and parenchyma on cursory examination at the autopsy. Still, these 
glands are frequently a source of trouble, not only in causing symptoms 
of tracheobronchial adenopathy, but also because these conditions are 
to be considered the forerunners of phthisis in the adult, though some 
look upon them as possible immunizing agents against reinfection in 
later life. 

By pressure these enlarged glands may cause stenosis of the main 
bronchus in children, while in adults it is less likely to occur because 
the bronchi are firmer. But the smaller bronchi may be compressed 
in adults as well as in children. In the latter, suppurating glands at 
times perforate the trachea, bronchi, pericardium, or esophagus, caus- 
ing sudden death, tuberculous bronchopneumonia, etc. 

The mesenteric glands are only rarely affected in adults, even in 
those who have tuberculous ulcerations of the intestines, but in 
children they are often found to be the seat of tuberculous changes, 
particularly with bacilli of the bovine type. This is in agreement 
with certain facts discussed in Chapter V. In primary infections the 
regional glands are invariably implicated. In secondary or metastatic 
infections the glands remain unaffected, as a rule. This rule holds good 
for the thoracic as well as for the abdominal glands. 

The Larynx. — The larynx shows tuberculous changes in at least 
one-third of the cases of phthisis. Proliferative and caseous, as well as 
ulcerative, lesions are found. These infections are usually secondary 
to tuberculosis in the lungs; primary tuberculosis of the larynx is 
exceedingly rare; in fact, some authors deny that it ever occurs. In 
many cases of laryngeal tuberculosis the trachea is also the seat of 
specific ulcerations. 

The Pleura. — The pleura is implicated in nearly every case of phthisis. 
A large proportion of cases are preceded by pleurisy, moist or dry, 
but even then it is usually secondary to extension of some small lesion 
in the lung. Pleural adhesions are found at the autopsy in nearly all 
fatal cases of phthisis, excepting those running an exceedingly acute 
course. In some cases they are so dense and compact that it is difficult 



154 



PATHOLOGY AND MORBID ANATOMY 



or impossible to remove the lungs without injuring the pleura. Some- 
times the pleura is thickened all over; in many only partly, especially 
over the seat of the main lesions, and also at the base where thickening 
of the diaphragmatic pleura is not uncommon with resulting elevation 
of the diaphragm. Many fibrous bands are often seen extending from 
the pleura into the parenchyma of the lung. The adhesions may be 
lax and easily separated, but in many cases they are dense, and when 
extensive the thick pleura may surround the lung like a shell. On rare 
occasions the pleura is even found calcified in places, or very extensively. 
Very frequently thickening of the pleura between the lobes of the lung 
is found. All these adhesions are great hindrances to the induction of 
artificial pneumothorax for therapeutic purposes. On the other hand, 
they prevent the occurrence of spontaneous pneumothorax through 
rupture of the visceral pleura over the site of superficially located 
pulmonary lesions, and when pneumothorax does occur, it is only 
localized. Serofibrinous pleurisy is quite frequent and, in fatal cases, 
exudations occur in a large proportion shortly before death. 




Fig. 17. — Tuberculous ulcerations of the intestines. (Tendeloo.) 



The Intestines. — The intestines are only rarely the seat of primary 
tuberculosis. In children it has been found between 30 and 50 per 
cent., and in adults Orth and Henke found it in 3 to 5 per cent, of all 
autopsies. But in phthisis they are secondarily affected to the extent 
of 90 per cent, of cases, according to some authors. Some of the 
anatomical changes are merely tuberculous nodules, but in most 
there are found round ulcerations of the mucous membrane of the 
ileus and colon, especially of the ascending colon (Fig. 17). These 
ulcers heal but rarely, though occasionally there is encountered a 
case of stricture of the intestine due to a contracted scar resulting 
from a tuberculous ulcer. On the other hand, these ulcers may per- 
forate into the peritoneal cavity with the usual results of these acci- 
dents. Ischiorectal abscesses are very frequent in phthisical patients. 

Amyloid Degeneration.— The tuberculous toxemia also causes changes 
in various other organs which, though not essentially tuberculous, 



PLATE IX 




\: 



m 




% 



1 



Liver Showing Amyloid and Fatty Degenerative 
Changes. 



EXTRATHORACIC PATHOLOGICAL CHANGES 155 

yet are more or less characteristic. Amyloid degeneration occurs 
mostly in chronic cases of mixed infection. The amyloid material is 
deposited in the walls of the capillaries outside of the endothelium, 
and pressing upon the lumen of the vessels, as well as the cells of the 
organ, prevents the nutrition of the parenchyma. The result is fatty 
degeneration and atrophy of the organ. We are in the dark as to the 
origin of this material. The liver, spleen, kidneys, and intestines are 
most frequently affected. Fatty degeneration of the liver is very 
frequent. In addition to the fatty and amyloid changes just mentioned, 
the liver and spleen often show frank tuberculous changes. R. G. 
Torrey 1 has recently reported 131 autopsies on tuberculous cases at 
the Phipps Institute as regards macroscopic and microscopic changes 
in the liver, spleen, kidneys, etc. In the vast majority of patients who 
succumbed to tuberculosis, tuberculous lesions were found in the above- 
mentioned visceral organs. O. Klotz 2 encountered tuberculous changes 
in the spleen in 172 out of 404 necropsies. A large proportion showed 
that the tuberculous lesions had healed. 

The Heart. — In the heart fatty degeneration is usually found in 
persons who succumb to phthisis. It is usually small, weak and 
atrophic, as are the rest of the muscles of the body. Hypertrophy of 
the right heart may be seen in cases of extensive shrinkage of the lung 
with pleural adhesions. Endocarditis verrucosa is also very frequent, 
but this is due to streptococci. In miliary tuberculosis miliary tubercles 
may be found in the myocardium, while in chronic phthisis they are 
rare. There have been reported some few cases of solitary tubercle of 
the myocardium. 

The Muscles. — The muscles are pale or brown, atrophied and poor in 
fat. Microscopic examination shows brown atrophy, fatty degener- 
ation and other degenerative changes. It appears that the diminution 
in the volume of the muscles is due to an atrophy in each individual 
muscle fiber, and not to diminution in their number. It should be 
mentioned that muscular tissue is never affected by tuberculous 
changes. 

1 Am. Jour. Med. Sc, 1916, cli, 549. 2 Ibid., 1917, cliii, 786. 



CHAPTER VII. 

SYMPTOMATOLOGY OF PHTHISIS— HISTORY OF THE 

PATIENT. 

We have seen that infection with tubercle bacilli does not invari- 
ably result in tuberculous disease. Phthisis implies a preexisting 
infection, but the latter may take place without any subsequent clinical 
manifestation of disease. The diagnosis of tuberculous infection is a 
simple matter. The application of the cutaneous tuberculin test tells 
the story promptly, easily, and unequivocally. The chances of error 
are insignificant and may be disregarded. 

But a positive tuberculin reaction, found in over 90 per cent, of 
humanity, as we have seen above, is by no means proof that the 
individual suffers from any disease or needs general or special treat- 
ment. It only shows that the individual has been infected with tubercle 
bacilli at some period of his or her life. The infection may not have 
done any harm. In fact, we have seen that, in all probability, it has 
immunized him against a new massive infection, which is difficult to 
avoid, and which might have produced acute and progressive disease, 
had it taken root on virgin soil. 

What we aim at in our practice is discovering not only tuberculous 
infection, but tuberculous disease. At any rate this is what the patient 
wants to find out: Whether he suffers as a result of the infection with 
tubercle bacilli and whether any treatment is necessary to save or pro- 
long his life. This information can only be given after a careful and 
painstaking inquiry into the patient's history, the symptoms he suffers 
from, and the physical signs elicited by an examination of his chest 
and other parts of his body, and applying some or all the clinical 
diagnostic methods which have been the achievement of medicine 
during the past couple of generations. 

Hazards of Hasty Diagnosis. — Realizing that the patient's chances 
of recovery are greatest when the disease is recognized and treated at 
its very incipiency, there has been a strong tendency during recent 
years to treat every " suspect" as one who is actively tuberculous until 
time and observation prove the contrary. This advice has been given 
by many writers on the subject and followed by numerous physicians. 
As a result many innocent persons have been banished to sanatoriums, 
or to distant climatic resorts; many children have been deprived of an 
education, many workmen induced to leave their employment, many 
men of affairs to neglect their business. To be sure, some of these 
non-tuberculous individuals — "suspects" — have been fatigued and 



HAZARDS OF HASTY DIAGNOSIS 157 

debilitated and needed a rest, and the error in diagnosis has rather 
benefited them. But with others things have been different. Many a 
person known to the writer has been trying to remove the stigma of 
tuberculosis without avail; and tuberculosis is a stigma at present, 
despite our teachings that a patient who has common-sense and decency 
is as good, and as harmless, as any other person. 

We often meet with people who had spent some few months in a 
sanatorium — from all indications they could have gotten along very 
well without it — and ever since they live in constant dread lest it will 
be found out that they had been "consumptives." I have known 
persons who have lost their jobs because some patient who knew them 
in an institution "gave them away." 

A hasty diagnosis among the poor and moderately well-to-do — from 
which classes the bulk of phthisical patients are being recruited — 
works even more havoc at times. The results of the maxim: "Treat 
everyone as tuberculous until he proves to you that he is not," can 
be seen in a city like New York where numerous individuals attend 
tuberculosis clinics for months, even for years, or go from one insti- 
tution to another for years, though they fail to present any reli- 
able symptoms of active phthisis. I witnessed the autopsy on the 
body of a woman who remained twenty-six years continuously in an 
institution; about one-half the time in a sanatorium, the other half 
in a hospital for advanced consumptives, where she finally died from 
pneumonia. Careful examination of the viscera failed to disclose an 
active tuberculous lesion. I calculated that the community spent, 
or wasted, over ten thousand dollars on this woman, not including 
the loss owing to her idleness. We may further mention that during 
the twenty-six years she kept out of the institution at least forty 
patients with active disease who might have benefited by the treatment. 

Many communities keep on spending considerable sums of money 
on the maintenance of patients who could be cared for in their homes 
at a lesser cost, or keep them from work merely because of a suspicion 
that they are tuberculous. Others break up their homes, commit their 
children to asylums because of a hasty diagnosis of incipient tuber- 
culosis based on some indefinite symptoms and physical signs. It was 
found in Germany, France, and England that some patients, passed 
for admission to sanatoriums because of incipient tuberculosis, were 
fit for active military service during the war. A large number of ex- 
sanatorium patients have been admitted to the United States Army 
and they make excellent soldiers. Fifty per cent, of patients in one of 
our largest municipal sanatoriums have negative sputum; that this 
is an indication that many are non-tuberculous will be agreed to by 
everyone who has any experience with tuberculosis. With the anti- 
formin method of sputum examination at most 10 per cent, of active 
cases are found not expectorating bacilli. 

There appears to manifest itself a reaction against the eager chase 
for "incipient" cases which may swell the favorable statistics of 



158 SYMPTOMATOLOGY OF PHTHISIS 

sanatoriums. Authoritative writers now state emphatically that 
indefinite physical signs should not be relied on, and urge that only 
constitutional symptoms of toxemia be taken as criteria for active 
disease. Edward O. Otis 1 questions the wisdom of relying on u the 
presence of certain physical signs, definite or indefinite, with no 
symptoms of bacterial toxemia which are interpreted to mean active 
tuberculosis, and the patient exhibiting such signs is accordingly 
removed from his family and employment and consigned to a sana- 
torium, where there is at least some risk that he may receive a new 
and active infection; whereas the individual was in no way ill, and 
probably never would have developed active clinical tuberculosis." 

The harm done to the community by the principle of treating all 
" suspects" as tuberculous has been shown drastically during the present 
war. At first physicians examining soldiers thought that they are 
dealing with their civil patients and were hasty in making diagnoses 
of tuberculosis. In civil practice these would be admitted into sana- 
toriums where they would remain for a variable time, and discharged 
as cured. But in the army they were taken to hospitals for observa- 
tion and the result was that in France of 1000 such men, only 1.5 per 
cent, were found to be actually sick with tuberculous disease, according 
to Kindberg and Delherm. 2 About 1 13 of the men were merely troubled 
with chronic nose and throat conditions. Major Rist 3 stated that out 
of 1000 men in the French army sent back to a base hospital as suffering 
with pulmonary tuberculosis, 807 were found to be non- tuberculous. 
I have had recently under my care many who have either been rejected 
by the draft boards, or by disability boards, because of alleged tuber- 
culosis which did not exist. The loss to the army in men and in money 
due to such hasty diagnoses cannot be overestimated. "The evils of 
such faulty diagnosis are world wide," says Colonel G. E. Bushnell: 4 
"they have been encountered in the armies of Germany and of Great 
Britain, as well as in that of France. There is the same blame for us if 
we err on the side of a too minute and pedantic regard for slight changes 
in breath sounds, or in percussion, for all the world is committing, or 
until recently has committed, the same mistake, and the standpoint 
is maintained by so many writers of repute that the unwary are scarcely 
to blame if they believe that it represents the standpoint of the truth." 
It is the opinion of Colonel Bushnell 5 that "medical officers should be 
held strictly responsible for the exercise of enlightened judgment as to 
causes which may or may not be evacuated from their hospitals." 

A hasty diagnosis is as dangerous as neglect to recognize active and 
progressive disease. Delay does not mean sure death of the patient; if he 
is kept under careful observation, we cannot be too late making a positive 
wsis. The acute and progressive cases will manifest themselves 






1 New Orleans Med. and Surg. Jour., 1914, lxvii, 311. 

2 Presse medicale, 1917, xxv, 645. 

3 Jour. Am. Med. Assn., 1917, lxix, 1265. * Medical Record, 1918, xcii, 4. 
t The Military Surgeon, April, 1918, xlii, 383, 






NATURAL METHOD OF ARRIVING AT A DIAGNOSIS 159 

very soon, and delay does not count because treatment in these cases 
is, as a rule, not very effective. In the slow, sluggish cases the delay 
of a few weeks hardly ever makes any difference in the ultimate out- 
come. But pronouncing a patient phthisical when, in fact, he has no 
symptoms of active disease, is often followed by disastrous results to 
the patient as well as to those depending on him, and to the community 
which is charged with caring for its tuberculous dependents. It may be 
said without fear of meeting contradiction from competent sources that 
an incipient case in the full sense of the word does not always mean a 
curable case, or even a favorable case. Many cases justly classed as 
incipient have a worse prognosis than those considered "far advanced" 
in the conventional classification of the disease. 

Elementary Principles in the Diagnosis of Active Phthisis. — Active 
tuberculosis, or phthisis, manifests itself invariably by symptoms of 
bacterial intoxication. If there are no symptoms of constitutional toxemia, 
the patient may have been infected with tubercle bacilli — and who has not 
been! — but he is not side with a disease which needs special treatment, 
costly to the community, and often ruinous to the patient and his family. 
Xor must the patient be isolated from his family, and hospitalized to 
prevent the dissemination of a disease which he does not have. This is 
a point which must always be borne in mind before a patient is told 
that he suffers from incipient phthisis. 

There is hardly a conscientious physician who is not skilled in making 
a diagnosis of incipient phthisis from the constitutional symptoms, 
even though he may have to leave the localization of the lesion to some 
virtuoso in physical diagnosis. There is no active phthisis without fever, 
cough, tachycardia, languor, nightsweats, hemoptysis, etc. Some or all of 
these symptoms are found soon after the patient becomes actively phthisical. 

If these elementary points were borne in mind by physicians, the 
number of mistakes of omission and commission would be reduced 
to a minimum. In fact, if the propaganda made so assiduously, 
aggressively and, within certain limits, justly, that to be cured, tuber- 
culosis must be discovered in its incipiency, would have insisted 
emphatically on the symptomatology of the disease, which can be 
inquired into, observed, and properly interpreted by every practising 
physician, all cases coming under the observation of physicians would 
be detected in proper time. It is wrong to blame the general practi- 
tioner for the large proportion of cases which are diagnosed rather late, 
after he has been taught that certain indefinite physical signs may mean 
phthisis, and just as often may mean nothing, In fact, the general 
practitioner may retort by saying that the large proportion of non- 
tuberculous cases admitted and kept in sanatoriums, as well as the large 
number of patients "cured" within two or three months in the insti- 
tutions, prove conclusively that the specialists are no less fallible in this 
regard. 

Natural Method of Arriving at a Diagnosis. — While in the practice 
of medicine we must often resort to the deductive method of reasoning 



160 SYMPTOMATOLOGY OF PHTHISIS 

when attempting to unravel an obscure case, yet in our attempts at 
ascertaining the presence or absence of active phthisis, we are on safer 
ground when applying the inductive method. We must first ascertain 
the individual symptoms and credit each with its true merit. In other 
words, all the morbid phenomena must be accurately observed; all the 
material facts are to be carefully inquired into; and, what is of most 
importance, the interpretation of the collected facts must be correct 
and in agreement as regards their relation one to another, and to the 
probable causes which may underlie the process. 

To do this rationally, we must carefully observe the appearance of 
the patient, go into details about the symptoms which urged him to 
seek medical advice and also inquire into such subjective symptoms 
as the average patient is not likely to note unless his attention is 
drawn to them. When all these data have been carefully gathered 
and properly evaluated, a physical examination is made to ascertain 
the objective signs of the disease, and these are correlated with the con- 
stitutional condition of the patient, with a view of ascertaining whether 
he is endowed with sufficient resistance to counteract the ravages of 
the disease. 

History of the Patient. — This is to be minutely inquired into. We 
find out the condition of health or the cause of death of the patient's 
parents and grandparents, if he is in possession of the facts, or capable 
of giving them to us reliably, which unfortunately is only rarely the 
case. Of particular importance is whether either of the parents was 
actively tuberculous when the patient was an infant. In case the 
parents have become actively tuberculous when the patient had 
already passed childhood, his chances of becoming phthisical are not 
greater than of those who do not have such a hereditary taint. In 
fact, there appears to be some evidence tending to show that, contrary 
to the general opinion, tuberculosis, if it occurs at all in such individ- 
uals, is apt to run a milder course than in those who have no family 
history of tuberculosis. 

We should not be influenced by the age of the patient. No age is 
immune to the disease, but each age period appears to have its own 
form of the disease: In infants hematogenic, general tuberculosis is 
the rule; in children tuberculosis of the glands, especially the tracheo- 
bronchial group, the bones and joints; in adults chronic pulmonary 
tuberculosis; in persons over forty fibroid phthisis, and in aged indi- 
viduals a very chronic form with a symptomatology peculiarly its 
own, etc. 

The occupation of the patient has great influence on the chances 
of developing active phthisis, as was already shown elsewhere, and 
should be considered when taking the history of the patient. A his- 
tory of an injury to the chest, especially if followed by hemoptysis, 
is important. 

Preexisting diseases are to be ascertained in detail. In infants and 
children active disease is apt to follow in the wake of one of the endemic 



HISTORY OF THE PRESENT ILLNESS 161 

contagious diseases; in adults, typhoid, influenza, pleurisy, pneumonia, 
diabetes, syphilis, etc., are of etiological moment. A history of scrofula 
during childhood has very little bearing upon active phthisis in the 
adult, excepting perhaps that if the disease does occur, it is likely to 
pursue a mild and exceedingly chronic course. The same is true to a 
certain extent of previous tuberculous disease of the bones and joints. 
One has to consider the rarity of old scars on the neck or over joints 
of phthisical patients; or of active and progressive phthisis in those 
who have had Pott's or hip-joint disease during childhood. 

In women the menstrual history is to be gone into, and special 
attention paid to amenorrhea. It is also to be borne in mind that 
active symptoms very often appear immediately after childbirth. 

A history of exposure to infection should not be overestimated in adults, 
as has been advised by many writers. We have seen that those most 
exposed to infection with tubercle bacilli, as the hospital staffs — 
doctors, nurses, and orderlies — are not more liable to become phthisical 
than those in other walks of life who do not come into intimate contact 
with consumptives; nor do the unaffected consorts of tuberculous 
patients suffer from this disease more than others. It is therefore 
absurd to expect that a tuberculous fellow-workman is more likely to 
transmit the disease than a hospital patient to a doctor, nurse or 
unaffected consort. In my own practice I do not at all give exposure to 
infection any weight in the diagnosis of active phthisis in adults. It is 
different with children, especially with infants. Infants of tuberculous 
parentage, or who have otherwise been exposed to infection, are very 
likely to have contracted the disease in an active form. With children 
over three we should ascertain whether the parent has become actively 
tuberculous while the child was less than one year old, because if the 
child was older than three years when the parent began to expectorate 
bacilli, the chances of primary massive infection of the child are remote. 

It is a curious fact that, in attempting to trace the source of infection 
in children, we often find it is one of the grandparents, suffering from 
senile phthisis, who is responsible, though he or she is ignorant of the 
true nature of the ailment, having been told that it is bronchitis, 
emphysema, asthma, etc. 

History of the Present Illness.— Of immense importance is the 
history of the mode of onset of the present ailment, as well as certain 
symptoms from which the patient has suffered during his lifetime. 
Previous attacks of "grippe," "colds," bronchitis, etc., may mean 
previous attacks of abortive phthisis and should be carefully considered. 
The same may be true of typhoid fever, pneumonia, and particularly 
pleurisy, etc., which may have beeu mild or severe attacks of tuber- 
culosis which have subsided. Having been treated for months for 
neurasthenia, gastritis, chlorosis, or even malaria, is not uncommonly 
ascertained in the history. 

We should inquire into the symptoms which ushered in the present 
ailment, with special reference to cough, expectoration, lassitude, 
11 



162 SYMPTOMATOLOGY OF PHTHISIS 

languor, particularly in the afternoon, loss of weight, hemoptysis, 
pleuritic pains, or pleurisy with or without effusion, etc. Of most 
importance in ascertaiaing the presence or absence of active disease 
is fever with its concomitant symptoms — chills, backache, anorexia, 
tachycardia, etc. Nightsweats are to be inquired into and it should 
be ascertained whether they occur immediately upon going to bed, 
or wake the patient at S3me time during the night. The appetite of 
the patient is to be ascertained, and whether any loss in this direction 
has been concomitant with the appearance of other symptoms. If 
the patient knows, he should tell the fluctuations in his weight for 
the past several years. The condition of the bowels, especially the 
presence of diarrhea, is to be ascertained. 

Of course, if any sputum is available it should be examined micro- 
scopically for tubercle bacilli, elastic tissue, and chemically for albumin. 
The urine should be analyzed for the presence or absence of albumin, 
sugar, and casts. 

After all these data have been ascertained, we proceed with the 
physical examination of the patient, and this includes not only a care- 
ful examination of the chest by inspection, palpation, percussion, and 
auscultation, but also all other parts of the body from the top of the 
head to the toes. We may thus find symptoms and signs confirming 
the diagnosis of phthisis, or proving that the symptoms of which 
the patient complains are due to some other cause. The stigmata 
of phthisis are often scattered all over the body, as will be shown 
later on. 

Above all, it must never be lost sight of that, while there is no active 
phthisis without constitutional symptoms, there is no single symptom 
or sign pathognomonic of the disease, excepting the expectoration of 
sputum containing tubercle bacilli, and even this is occasionally apt 
to mislead. It is only the combination and correlation of various 
symptoms and signs which clinch the diagnosis, especially in obscure 
cases with negative sputum. This fact by no means interferes with 
the early recognition of active phthisis, and mistakes are more often 
due to carelessness in observation than to any other factor. 

Importance of the Symptomatology of Phthisis. — In the succeeding 
chapters the physical diagnosis of phthisis in its various forms will 
be given its proper place, because only with the aid of inspection, per- 
cussion, and auscultation can we localize the lesion and gain impor- 
tant hints as to prognosis and the treatment indicated. The symp- 
tomatology of the disease, which has been given a subordinate place 
in some recent treatises on the subject, will be discussed in detail. 
The jeasons are obvious. The general symptomatology of active 
phthisis can be ascertained by every practising physician and its 
bearings on the presence or absence of active phthisis, especially in 
doubtful cases, are of more significance than indefinite physical signs. 
There may be active phthisis without physical signs revealing themselves 
even to the best-trained specialist, and many signs of apical involvement 



IMPORTANCE OF THE SYMPTOMATOLOGY OF PHTHISIS 163 

are found in healthy persons. But there is no active phthisis without 
constitutional symptoms. This is an axiom which cannot be repeated 
too often. The symptomatology of phthisis, when properly studied and 
interpreted, gives information as to the onset of the disease, its activity, 
tendency, and ultimate outlook. It can be ascertained by any medical 
man. Inasmuch as it often precedes the appearance of definite physical 
signs, or the signs elicited with the aid of skiagraphy, the symptom- 
atology of the disease is to be ascertained first. 

We shall therefore begin with a discussion of the most prominent, 
and more or less constant, symptoms of active phthisis — cough, 
expectoration, fever, nightsweats, hemoptysis, anorexia, emaciation, 
tachycardia, etc. Each of these symptoms will be discussed from the 
standpoint of diagnosis, differential diagnosis, and prognosis. It is 
only by a proper appreciation of these symptoms that a diagnosis of 
active phthisis can be made at any stage of the disease, but especially 
in the so-called incipient stage; while a prognosis based only on findings 
during a physical examination and skiagraphy is bound to prove 
ruinous to any practitioner. 



CHAPTER VIII. 
COUGH AND EXPECTORATION. 

COUGH. 

Frequency of Cough. — While cough is the symptom which first 
attracts the attention of the average patient to his troubles, there has 
been a question whether there are cases of phthisis without cough. 
Pidoux stated that cough is the first and last symptom of phthisis; 
when it is absent, its negative significance is almost absolute. Accord- 
ing to many writers, a patient who does not cough is not tuberculous, 
while there are others who consider it the most constant of symptoms 
of early phthisis. However, Louis, Wilson Fox, Moeller, and others 
speak of patients who passed through the disease without ever coughing. 

This disagreement is due to various causes. The statement made by 
many phthisical patients to the effect that they do not cough is to be 
taken with considerable reservation. Mild cough, clearing the throat 
in the morning, or hawking, which causes but little annoyance to 
individuals who are not given to introspection, may be overlooked. 
Even in the advanced stages, when the patient brings up considerable 
sputum, there may be no cough — the sputum is carried by the cilia of 
the bronchial mucous membrane and when it reaches the vocal cords it is 
easily removed without effort, or swallowed. In the latter case the patient 
may not even expectorate. I have seen this to be the case with many 
patients, especially females. For this reason, it is often ascertained by 
close questioning that there is a little, mild cough, "just like everybody 
else coughs." I have, however, seen many patients in whom physical 
exploration of the chest was negative for quite some time, but the 
continuous cough, productive or unproductive, was the only symptom 
which urged them to seek a diagnosis, and excited a careful study of 
the case by the physician. 

Another class of patients who do not cough despite active tuber- 
culosis are aged persons, of whom details will be given later on. The 
same is true of some cases of phthisis with cavities — mouthfuls of 
sputum may be brought up without any effort, or cough, as in bron- 
chiectasis. 

Cough in the Early Stage of Phthisis. — A considerable number of 
patients give a history of repeated " colds" caught during several 
preceding winters or autumns; or of attacks of "grippe" which made 
them cough more or less violently, but they subsided under ordinary 
treatment. Owing to some neglect, the last attack has been per- 
sistent, the cough aggravated, and could not be relieved by the remedy 



COUGH 165 

which helped them formerly. The cough in these cases is apt to be 
rather mild, consisting mainly in clearing the throat in the morning, 
and may not at all be productive of sputum; or small lumps of clear 
vitreous secretion from the nasopharynx may be brought out. Rarely 
mucopurulent material is eliminated, but it is usually devoid of tubercle 
bacilli at this stage. 

These repeated attacks of "grippe," or bronchitis, which subside 
during the summer, to return during the autumn and winter, and are 
easily managed by ordinary sedatives, often give the patient a false 
sense of security, and when told that the cough is of tuberculous origin 
he is loath to agree to it. 

This mild cough is to be differentiated from hysterical cough, which 
is very frequent at present when phthisiophobia is rampant. In fact, 
in many homes with tuberculous patients, notably after a consumptive 
dies in the house, most of the healthy members of the family cough, 
believing they are affected with the disease. Perhaps the best sign is 
that hysterical cough does not occur at night, when the patient is asleep, 
or during the day, when he is absorbed in some matter which interests 
him. I have seen patients who coughed persistently, cease coughing 
during the time they were engaged in an interesting conversation. 
In many cases the cough in incipient phthisis is annoying at bedtime, 
disappearing during the first hours of sleep, and reappearing during the 
early morning hours, often waking the patient, while after rising it 
may be intense until the chest is cleared. During the day it may be 
scarce or absent and provoked only by emotional disturbance, undue 
exertion, chilling the body, a dusty or smoky atmosphere, etc. 

Paroxysmal Cough. — In many patients at the onset of the dis- 
ease, or during its later stages, the cough is violent and paroxysmal; 
occurring in fits. When unproductive, it may be difficult to bear 
because it often increases in intensity during the evening, and keeps 
the patient awake during the night, causing pain in the chest, insomnia, 
and exhaustion. In others, the fits keep up for quite some time till a 
small piece of viscid mucus is expelled. The first thing these patients 
ask for is a remedy which will loosen the sputum. During such spells 
vomiting may occur, or even involuntary evacuation of urine, espe- 
cially in women with lacerated genitals. The paroxysmal explosions of 
cough are a frequent cause of hernia in men, especially in those suffering 
from fibroid phthisis. 

Paroxysmal cough in phthisis is said to be due to ulceration of the 
trachea at its bifurcation. But it is also met with in cases of tracheo- 
bronchial adenopathy. Its occurrence during periodical evacuation 
of pulmonary cavities will be discussed later on. 

Patients suffering from fibroid phthisis, and those who have tuber- 
culosis evolving in emphysematous lungs, suffer at times from severe 
paroxysms of cough. In these the cyanosis of the lips and finger-tips, 
and bulging of the veins of the neck are strong features during a 
paroxysm, and the suffering may be extreme. The violence of the cough 



166 COUGH AND EXPECTORATION 

is usually far out of proportion to the amount of sputum brought up. 
After the expulsion of a small lump of transparent mucus they feel 
relieved but exhausted, to be annoyed again at longer or shorter 
intervals. Nocturnal attacks are not uncommon. 

I have observed similar paroxysms of violent cough in many cases 
of galloping consumption in which the lesions could not be localized; 
also in miliary tuberculosis with tubercles widely disseminated all over 
the lungs, and signs of pulmonary emphysema were elicited on physical 
exploration of the chest. The violence of the cough may be responsible 
for the extensive dissemination of the tubercles by metastasis. But 
in many cases under my care the lesion finally localized itself, and the 
disease pursued the usual course of chronic phthisis, the paroxysmal 
cough disappearing, leaving the common cough encountered in the 
average case of the disease. 

The Emetic Cough. — First described by Richard Morton at the 
end of the seventeenth century, the cough ending in vomiting, is quite 
frequently met with in the early stage of phthisis in various degrees 
of intensity. Some French authors, notably Paillard, 1 state that the 
signe de Morton, or the toux emetisante, as they call it, is met with to 
the extent of 50 to 60 per cent, of all cases of phthisis. This has not 
been the case with the patients under my care. To be sure, vomiting 
may be seen in more than one-half the cases of tuberculosis at some 
period of the course of the disease, but not all vomiting can be con- 
sidered the true emetic cough, as we shall soon show. 

It has been stated that the cough of incipient phthisis often produces 
no expectoration, but vomiting. There are tuberculous patients who 
cough as soon as they eat, says Michel Peter, 2 there are others who 
cough because they eat; finally, there are others who, having eaten, 
cough, vomit, and suffer from cardiac palpitation. This emetic cough 
is so characteristic that when whooping-cough and rhinopharyngitis in 
chronic alcoholics are ruled out, 1 place great reliance on it in doubtful 
cases, and it has often helped me in making a positive diagnosis sooner 
than I could have made it without this symptom. But to appreciate 
its diagnostic significance it must not be confounded with vomiting of 
other origin which may occur in phthisis. It usually occurs in the 
following manner : 

The patient has had his lunch, or dinner, with a variable appetite and 
feels rather satisfied, having no sensation of gastric disturbance, except- 
ing perhaps some feeling of epigastric distention, or mild dyspnea. But 
after the lapse of some time, from five minutes to an hour — an average 
of about twenty minutes — the patient, either without any warning at 
all, or feeling some irritation at the back of the throat, is seized with a 
paroxysm of cough which nearly chokes him; he feels as if he is unable 
to expel a piece of tenacious mucus which sticks in his throat. Finally 
he vomits out, in part or completely, the gastric contents which are 

1 La toux emetisante des tuberculeux, Paris, 1911. 

2 Legons de Clinique medicale, Paris, 1879, ii, 318. 



COUGH 167 

io a variable state of digestion, according to the time they remained in 
the stomach. There is no sensation of nausea before the paroxysm, but 
the vomiting comes on suddenly during the coughing spell; a fact 
wbich differentiates this form of vomiting from other forms. When 
occurring for the first time the patient is alarmed, or may be inclined to 
attribute it to some dietetic indiscretion, but if it occurs repeatedly 
he is compelled to seek another cause. As soon as the vomiting ceases 
the patient usually feels greatly relieved, the sensation of gastric 
distention and the dyspnea disappear, and at times he may express 
a desire to eat again. After a time the patient learns prudence from 
experience — he knows that a heavy meal may bring about a fit of 
cough followed by vomiting. 

During the course of phthisis there occur also other varieties of 
vomiting which cannot be classified under the heading of emetic cough. 
Patients who have been sufferers from chronic gastritis, dilatation of 
the stomach, and chronic alcoholism often vomit; at times vomiting 
is provoked by cough. In the advanced stages of the disease vomiting, 
preceded by cough or not, may cccur and in some patients it may be so 
pronounced as to preclude feeding. But these forms of the vomiting 
are not the true emetic cough. These patients usually suffer from 
symptoms of indigestion — furred tongue, foul breath,- constipation, 
diarrhea, headache, etc. Examination usually reveals a dilated 
stomach, amyloid, or fatty degeneration of the liver, symptoms of 
tuberculous peritonitis, etc. Moreover, while the vomiting may occur 
after coughing, yet it is not invariably preceded by paroxysmal cough, 
occurs irregularly, not always after the ingestion of food, and there is no 
relief immediately after the vomiting. In alcoholics the vomiting is 
more apt to occur in the morning, and this is also the rule with those in 
whom the cough is due to chronic pharyngitis. In both these condi- 
tions, nausea, retching, etc., are common, while in the true emetic 
cough they are absent. The emetic cough often occurs in the early stages 
of phthisis, in patients in whom the gastric functions are in good condition, 
is always preceded by spells of cough, always occurs at a certain time 
after the ingestion of food, is not preceded nor followed by sensations of 
nausea, giddiness, faintness, and retching. The reverse, vomiting and 
then coughing, is never observed. 

This form of vomiting, or the emetic cough, is observed in practice 
in but a few diseases, namely, phthisis, whooping-cough, and in certain 
forms of pharyngitis, especially in alcoholics. So that when whooping- 
cough is excluded in a patient with an emetic cough, and the pharynx 
is found to be in good condition, phthisis is at once to be thought of. 
If it persists, a diagnosis of tuberculosis may be made even in the 
absence of definite physical signs of the disease. 

Some authors have been inclined to look at the emetic cough as a 
mechanical accident, comparable with that observed in whooping- 
cough. But it appears that this does not entirely explain this phe- 
nomenon. If the compression of the abdominal muscles and stomach 



168 COUGH AND EXPECTORATION 

were the sole cause, we should expect vomiting to occur during vio- 
lent and prolonged asthmatic paroxysms. But I have never seen a 
patient suffering from asthma vomit after an attack of cough and 
dyspnea, and be relieved immediately after the gastric conten+s have 
thus been expelled. 

As has been pointed out by Michel Peter, W. Soltau Fenwick, 1 
Paillard, and others, the emetic cough appears to be purely a leflex 
phenomenon, due to irritation by the ingested food of the gastric ends 
of the vagus, and an abnormal excitability of the respiratory center. 
Hence, the slightest irritation of the gastric mucous membrane by 
particles of food is sufficient to produce a violent attack of reflex cough 
which can bring about vomiting in a mechanical manner. 

Cough during the Advanced Stages of Phthisis. — With the advance 
of the disease the cough becomes more and more abundant, more 
productive, but easier, and less exhausting. After the formation of 
cavities, there is usually observed a diminution in the frequency of the 
cough, sleep is hardly disturbed during the night when the reflexes are 
in abeyance, and the secretions accumulate in the cavity. But in the 
morning, when compelled to empty the cavities of the secretions, there 
are fits of coughing lasting several minutes, perhaps an hour, and the 
patient feels relieved. 

These patients, like those suffering from bronchiectasis, suffer from 
cough periodically when the excavations have been filled and need 
emptying. It may be influenced by posture — as soon as they change 
their position, the secretions overflow the bronchial tubes and must 
be brought out by cough, which does not cease until all has been dis- 
charged. Then there is relief for a variable time until the cavity is 
again filled. The patients usually learn from experience on which side 
to sleep if they want to have peace. It is not always on the healthy 
side on which they can lie with more or less comfort, because, like in 
bronchiectasis, it depends on the direction of the bronchus, or sinus, 
which empties the cavity. Patients with pleural effusions also cough 
when changing their positions, but in their case the cough is usually 
dry, and is not instrumental in bringing up abundant sputum. For 
obvious reasons, patients cough more when lying down than when in 
the upright position. But in others sitting up in, or getting out of bed 
excites a paroxysm of cough and expectoration. 

In some cases the cough at this stage is very severe and almost 
incessant, painful, and preventing rest day and night; actually exhaust- 
ing. It is noteworthy that the severity of the cough does not alto- 
gether depend on the extent of the lesion in the lung, nor on the size 
and number of the cavities. Some will cough very little, although the 
lungs are extensively involved, while others, with limited infiltrations 
or excavations, cough severely. 

The cough of tuberculous patients is often greatly influenced by 

i The Dyspepsia of Phthisis, London, 1894, p. 118. 



COUGH 169 

various factors, of which the age and the emotional state are most 
important. Young adults cough, as a rule, more than old consumptives. 
In fact, a large proportion of old people suffering from phthisis hardly 
cough; they bring up large quantities of sputum without any effort. 
They are the patients who supply the material for those who describe 
cases which have been sick with tuberculosis for many years and never 
coughed. The psychic state of the patient also has a great influence. 
The nervous, irritable, and hysterical, cough more than the indolent 
and phlegmatic. The former class is also more apt to suffer from the 
emetic form of cough. 

Diagnostic and Prognostic Significance. — On the whole, cough serves 
a very good purpose by drawing the attention of many patients to 
the condition of their lungs. A person who never coughed, but "caught 
cold" for the first time after his twentieth year, and as a result keeps on 
coughing for more than a month, is to be strongly suspected of being 
tuberculous, even if there are no definite physical signs of a pulmonary 
lesion. The suspicion is fortified by a history of the absence of acute 
coryza during the first few days of illness, because simple bronchitis 
and "grippe" are almost always preceded or accompanied by naso- 
pharyngeal catarrh. 

From the prognostic viewpoint cough is important because we 
meet cases with small pulmonary foci without much fever, anorexia, 
emaciation, etc., who would undoubtedly do well, but for a cough 
which is difficult to control. If violent, paroxysmal, and continuing 
for some time, the cough may be instrumental in extending the lesion, 
exhausting the patient, and thus aggravating the outlook. It also 
irritates the larynx, trachea, bronchi, and pulmonary parenchyma, 
and predisposes these organs to infection by metastasis of the bacilli. 
Violent fits of cough may also be responsible for spontaneous pneumo- 
thorax in cases in which the lesion is located superficially or subpleurally. 
Kuthy and Wolff-Eisner 1 say that the most unfavorable prognosis is 
to be given in cases in which the patient coughs during both day and 
night; relatively more favorable is the outlook when he coughs during 
the day exclusively; more favorable when he coughs only mornings 
and evenings; and most favorable when he coughs exclusively in the 
morning. 

Within certain limits cough also gives other prognostic hints. With 
each improvement in the local or general condition, the cough also 
improves or disappears, and with every recrudescence of cough we 
may find an extension of the process in the lungs, or some complication 
in the bronchi or nasopharynx. Occasionally we may note that the 
sudden disappearance of cough is a signal of some grave complication 
of phthisis, especially meningitis or peritonitis. The same is at times 
seen in cases of severe ulcerations of the larynx, causing dysphagia, 
etc. The cough may be ameliorated, but the lesion in the lungs con- 

1 Die Prognosenstellung bei der Lungentuberkulose, Berlin, 1914, p. 219. 



170 COUGH AND EXPECTORATION 

tinues or extends and, combined with the exhaustion due to lack of 
nourishment, the end is not very far. 

Hoarseness. — Changes in the timbre of the voice may appear quite 
early in the disease without any tuberculous involvement of the larynx. 
The least provocation, such as changes in the weather, or prolonged 
speaking, may produce dysphonia, or a muffled voice, without any 
pain which, with the dyspnea' prevent'ng speaking continuously long 
sentences, may be quite troublesome. 

In many cases the hoarseness is due to simple catarrh caused by 
chemical irritation of the larynx by the secretions while they are being 
eliminated from the lungs. In others, pressure of a tuberculous gland, 
lying between the trachea and the esophagus, on the recurrent laryn- 
geal nerve causing adductor paralysis, is the cause. Reflex irritation 
of the superior laryngeal nerves may also be the cause of hoarseness. 
Often the hoarseness is due to tenacious secretions sticking to the vocal 
cords, and after coughing strongly they are dislodged and the voice 
is again normal. Congestion of the larynx caused by violent fits of 
coughing may be the reason for hoarseness. 

It is thus evident that not all case? of hoarseness, or even dysphagia, 
are due to tuberculous ulcerations of the larynx. In fact, no diagnosis 
of the latter condition should be made without a careful and pains- 
taking inspection of the larynx with a mirror. 

EXPECTORATION. 

Careful inquiry reveals in most cases that the cough preceded expec- 
toration by several weeks or even months, and we must not unequivo- 
cally conclude that because the cough is unproductive we are not deal- 
ing with phthisis. Children before the sixth year never bring up any 
sputum at all, because they unconsciously swallow it, and most women 
do the same. I have met with cases in which urging women to expec- 
torate was of no avail. Many men are not much better in this regard 
and, for reasons of false delicacy, they swallow the sputum, especially 
during the early stages of the disease. In the advanced stage we may 
meet with the same condition when the emaciated patient is exhausted 
and hardly has any strength to rise, or turn around, in bed and expecto- 
rate into the sputum cup. 

With the advance of the disease the quantity of sputum eliminated 
increases, but I have met with cases showing extensive infiltrations of 
more than one lobe, without any substantial expectoration, and in 
some of these I have been convinced that they had not swallowed the 
sputum. It was merely an indication that the tubercles had not 
broken through a bronchus, or that the cavities were "dry." 

Macroscopic Appearance of the Sputum. — There is nothing typical 
about the naked-eye appearance of the sputum in early phthisis, 
although ancient clinicians gave detailed descriptions of typical tuber- 
culous sputum. Perhaps the fact that they knew very little about 



EXPECTORATION 171 

early phthisis will account for their confidence in the gross appearance 
of the sputum in this disease. 

In the early stages we find that the sputum is scanty; at times it 
is altogether absent. Kuthy found that in 49 per cent, of cases in the 
first stage, 15.4 per cent, of the second stage, and 12 per cent, of the 
third stage, sputum was altogether absent. What is usually brought 
up in the early stages is viscid mucus, occasionally with some dark 
specks; it is often frothy and floats on water, hardly differing from the 
expectoration in bronchitis. 

With the advance of the disease the sputum becomes thicker, 
although it remains glassy or transparent for some time, but yellow 
streaks are to be seen, indicating that it is assuming a purulent char- 
acter. Later its appearance and consistency change: It becomes 
mucopurulent, and finally purulent, indicating that softening of lung 
tissue has taken place and the necrotic parts are being eliminated. 
The purulent character of the expectoration is judged by the yellow, 
yellowish -green, or green color it assumes. Pure purulent sputum, 
without froth, is mostly seen in cases in which an abscess or pyopneumo- 
thorax has broken through a broachus. 

In the far-advanced stage of the disease the sputum is usually dark 
gray, or greenish in color, made up of roundish balls which" float around 
like islands in the fluid mucus or saliva or, when thicker in consistency, 
sink down to the bottom of the receptacle, where it settles in disk or 
coin-shaped masses which keep apart and do not coalesce. This is 
the nummular sputum of old physicians which had erroneously been 
considered pathognomonic of phthisical excavations. At times whitish, 
cheesy masses, derived from broken-down tubercles, are seen scattered 
within this sputum. 

This sputum is usually odorless, but at times it acquires a very 
disagreeable, sweetish, but nauseating odor, especially when retained 
within the chest by narcotic drugs, or weakness of the patient. Fetid 
and offensive sputum is exceedingly rare in phthisis. Whenever it 
is met with we should look for complicating pulmonary gangrene, 
which occurs at times. Very rarely it is due to fetid bronchitis. It is 
usually salty in the early stages of the disease, but later it often acquires 
a sweetish, sickening taste. 

Very often this sputum, derived from tuberculous cavities, when 
allowed to stand in a vessel for some hours separates into three layers 
— an upper frothy layer; a middle thin serous layer; and a lower 
layer consisting of thick plugs of pus. This is characteristic of exca- 
vation but not of necessarily tuberculous origin. Bronchiectasis and 
chronic bronchitis with copious expectoration may also be productive 
of sputum which separates on standing. However, in the former the 
lines of demarcation between the layers are not so distinct, but one 
passes into the other by slow gradations. 

There are cases of advanced chronic phthisis with scanty, or even 
without any expectoration, especially those of the type of fibroid 



172 COUGH AND EXPECTORATION 

phthisis, cr with emphysema, although they have periods in which 
the expectoration is quite profuse. The expectoration decreases in 
quantity when the cavities " dry up" during the process of healing, and 
in other types of cases when the concomitant bronchitis disappears. 
"With but few exceptions, scanty expectoration speaks for a favorable 
outlook, piovided the cough is also absent or mild. On the other hand, 
copious expectoration per se is not always an unfavorable sign. It is 
an indication of excavation, bronchitis, or bronchiectasis which are 
not infrequent in phthisis. In the latter cases the sputum may show 
a tendency to collect and be expelled at intervals in very large quanti- 
ties — mouthfuls — without any effort, and may also be influenced by 
posture. 

During hemoptysis the material expectorated is sanguineous in various 
degrees, corresponding to the severity of the bleeding, and for a few 
days after the cessation of the active hemorrhage the sputum contains 
dark clots derived from the blood that has coagulated in the bronchi 
and is being slowly eliminated. The sputum may have a reddish or 
chocolate tinge without distinct hemorrhage, and even rusty sputum 
characteristic of pneumonia is at times encountered in phthisis. Inas- 
much as this is, as a rule, seen during an acute exacerbation of fever, 
etc., I am inclined to account for it, in many cases, by intercurrent 
pneumonia. In some advanced cases I have seen at the terminal stage 
thin, watery sputum, dark brown in color, with numerous air bubbles — 
prune-juice sputum — which is an indication of pulmonary edema. 
Green sputum is at times met with, and is usually ascribed to the 
implantation of the Bacillus pyocyaneus. In cases in which a pyo- 
pneumothorax communicates with a bronchus, as well as when an 
empyema breaks through a bronchus, the sputum may be distinctly 
purulent, and I have seen cases in which the empyema was thus cured, 
though the tuberculous process went on its course. 

EXAMINATION OF THE SPUTUM. 

Collection of Specimen. — In cases of suspected phthisis the sputum 
gives important information which is often of more value than all 
other diagnostic methods for this disease taken together. This is 
especially true of the microscopic examination, and to a certain extent 
of the chemical examination. 

It is important, especially in cases with scanty expectoration, that 
the specimens of sputum for examination should be properly collected. 
The patient must be warned that what we want is material that has 
been coughed up from beneath the glottis, and not what has been 
hawked out from the nasopharynx or saliva. A clean, wide- mouthed 
bottle is the best receptacle, and it should be tightly corked. The one 
used by the Health Department in New York City is excellent. In 
cases with scanty expectoration, a twenty-four-hour specimen is 
desirable, but with others the quantity coughed up during the morning 



EXAMINATION OF THE SPUTUM 173 

on rising is sufficient. Fresh sputum is best, but putrefaction does 
not interfere with the appearance of the bacilli under the microscope. 

It must be emphasized that really active cases of tuberculosis with 
persistently negative sputum are rare. Most of these cases, if ex- 
amined repeatedly, will show the presence of tubercle bacilli in the 
sputum. In my wards at the Montefiore Hospital we often find that 
these " closed" cases show the presence of bacilli after several exami- 
nations of the sputum. In some it takes as many as twenty micro- 
scopic examinations to find one positive. But it is doubtful whether 
a patient who shows persistently negative sputum is in fact sick with 
tuberculosis requiring treatment, and I have been under the impres- 
sion, based on good evidence, that the sanatoriums which have as 
many as over 50 per cent, of "sputum negative" cases have an 
enormous proportion of non-tuberculous cases within their walls. I 
doubt whether more than 10 per cent, of these " sputum negative" 
cases are tuberculous in the clinical sense. 

On the other hand, it is wrong to consider a case as not contagious 
because the sputum is negative. We are of late beginning to realize 
that the sputum alone is not the only way in which tuberculosis is 
transmitted from the sick to the well. This point has been discussed 
in detail elsewhere in this book. 

Microscopic Examination. — In incipient cases tubercle bacilli are 
more often absent than present in the sputum, and it is only when 
softening of tubercles has taken place and the diseased focus opens into 
a bronchiole that they can be found. In general, it may be stated 
that severe cases show large numbers of bacilli, but there are many 
exceptions. In fact, in acute pneumonic phthisis bacilli are often 
lacking. The absence of bacilli is therefore not conclusive proof of 
the non-tuberculous character of a case, because we meet with un- 
doubted cases of tuberculosis, proved by subsequent autopsy findings, 
in which no bacilli were discovered throughout the course of the 
disease. In general, it may, however, be stated that these "closed" 
cases of tuberculosis run a more favorable course. On the other hand, 
in acute miliary tuberculosis, tubercle bacilli are discovered in the 
sputum in exceedingly rare instances. 

In early phthisis in which it is difficult to obtain sufficient sputum 
for examination, the administration of iodides, 5 grains three times 
a day for a couple of days, may increase the amount of expectoration. 
We may, in some cases, also administer an opiate in the evening with a 
view of retaining the sputum during the night, so that it may be 
brought up in the morning on rising. In children, swabbing the 
throat with some gauze, as suggested by Holt, may yield a specimen 
for examination, though in my hands it has invariably failed. 

Technic. — The examination is best and most rapidly accomplished 
by the Ziehl-Neelsen, the Gabbet, or the Hermann methods, which 
have survived numerous modifications introduced during recent 
years. 



174 COUGH AND EXPECTORATION 

With a platinum-wire loop a cheesy or mucopurulent particle is 
picked out and spread over a perfectly clean cover-glass in a thin, 
uniform layer. It is even better that a small amount of sputum 
should be spread between two cover-glasses which are drawn apart. 
The cover-glass is dried in the air, or over a Bunsen burner at some 
distance from the flame. When dry, it is "fixed" by passing it three 
or four times through the flame. Some of the solution (carbol-fuchsin, 
1; absolute alcohol, 10; carbolic acid, 5; and distilled water ad. 100) 
is put on the specimen which is picked up with a Cornet forceps and 
held over the flame for about three minutes or more until it steams, or 
bubbles appear over it. It is then decolorized in a 10 per cent, solution 
of nitric acid, or a 30 per cent, solution of sulphuric acid and washed 
in 60 per cent, alcohol, until it is completely colorless, when it is counter- 
stained with an alcoholic solution of methylene blue, washed in water, 
and dried between filter paper. 

With Gabbet's method the staining with carbol-fuchsin is the same 
as above, but the decolorization and counterstaining are done together 
by placing the specimen in Gabbet's solution (methylene blue, 2; 
sulphuric acid, 25; distilled water, 75). 

The Hermann stain is also easy; it consists in: (a) Crystal violet, 
3 per cent, in alcohol; (b) ammonium carbonate, 1 per cent, solution 
in water. Mix one part of solution a with three parts of solution b 
just before using. Steam as above, decolorize with 10 per cent, nitric 
acid, wash in alcohol, and counterstain with Bismarck brown. At 
times this method will reveal bacilli when the above have failed. 

These methods will disclose the bacilli in the vast majority of cases, 
but they fail at times because of the small amount of sputum avail- 
able, or the small number of bacilli present in the specimen, or the 
selection of a particle of sputum with the platinum loop which does 
not contain any bacilli. To obviate these sources of error there have 
been devised new methods which liquefy the sputum, digest all the 
cells and bacteria which may be present, excepting the tubercle bacilli, 
which can be centrifuged and be examined microscopically, and may 
even be used for cultural purposes or for injections into animals. The 
antiformin method is at present the best and simplest available for 
the purpose. 

The Antiformin Method. — Devised by Uhlenhuth and Xylander, 
and modified by others, this method consists in mixing the sputum 
with antiformin — a strongly alkaline mixture of sodium hypochlorite, 
equivalent to 5.68 gms. available chlorine; sodium hydroxide, 7.8 
gms., and sodium carbonate, 0.32 gm. — used by brewers in the disin- 
fection of their fermentation vats and tubes. When properly diluted 
and mixed with sputum, there is a strong liberation of gas, the insol- 
uble organic matters, as well as bacteria, are destroyed, excepting hair, 
fat, wax and cellulose, and acid-fast bacilli, the vitality and staining 
reactions of which remain unchanged. The resulting yellowish solu- 
tion is a homogeneous mixture with a flocculent sediment. Because 



EXAMINATION OF THE SPUTUM 175 

it has a fatty capsule the tubercle bacillus remains intact while all 
other microorganisms are rapidly destroyed. 

Of the various modifications of Uhlenhuth's original method, the 
one devised by Boardman 1 is the most serviceable. It consists in: 

1. Place the entire twenty-four-hours' sputum in a conical settling 
glass; if the amount is excessive it is perhaps better to use only 15 to 
20 c.c. 

2. If the specimen is thick, add an equal volume of distilled water. 
Less tenacious specimens do not require so much dilution. 

3. Add an amount of antiformin equal to one-fourth the volume of 
the diluted sputum; in other words, sufficient to make a 20 per cent, 
solution. 

4. Stir thoroughly, thereby breaking up the masses of mucus and 
greatly hastening complete solution. 

5. Allow to stand till solution appears homogeneous. It should now 
be watery in consistency and pale yellow in color; if necessary, more 
water or more antiformin should be added and digestion allowed to 
continue. This will usually require from a few minutes to an hour 
but may be allowed to continue for days with no resulting harm to 
the tubercle bacilli. 

6. Add an equal volume of 95 per cent, alcohol. By this procedure 
the specific gravity is reduced from about 1.030 to below 1; thereby 
not only hastening sedimentation, but making it more complete. 

7. After stirring, allow to stand till sedimentation is complete. This 
will occur in from two to four hours, but a period of twelve to twenty- 
four hours is recommended. During this sedimentation it may be 
necessary to gently turn the vessel to dislodge little particles of sedi- 
ment which may be adhering to the sides of the vessel. 

8. Pour off the clear supernatant fluid. 

9. Make smear from sediment on a glass slide, using some of the 
original sputum to aid in fixing the smear. This is best done by 
making a smear from the sputum before antiformin is added and 
afterward spreading the sediment from the sputum-antiformin mixture 
on the same slide. Stain in the usual way. 

There are many modifications of this method which do not require 
twenty-four hours for execution. Loeffler's modification, which takes 
but ten minutes, is the best : 

A certain quantity of sputum (10 to 20 c.c.) is mixed with an equal 
quantity of 50 per cent, aqueous solution of antiformin and boiled 
over the flame. Rapid liquefaction is observed. To each 10 c.c. of 
the mixture, 1.5 c.c. of a 10 per cent, alcoholic solution of chloroform 
is added. After stirring for some time the solution is centrifuged for 
about fifteen minutes. The disk which forms on the surface of the 
chloroform contains the tubercle bacilli, and is to be pipetted, fixed 
with egg albumen, and stained in the usual way. 

] Johns Hopkins Hosp. Bull., 1911, xxii, 269. 



176 



COUGH AND EXPECTORATION 



The great importance of the antiformin method lies in the fact that 
it exerts a destructive action on all cells and microorganisms excepting 
the acid-fast rods which may then be found microscopically. But 
soon after its introduction it was found that acid-fast rods which are 
not pathogenic, and which are often found while looking for tubercle 
bacilli, may escape destruction by the antiformin, thus causing mis- 
takes. Especially was the question whether the smegma bacillus is 
dissolved by this agent important. In a recent investigation of this 
problem by von Spindler-Engelsen, 1 she found that the smegma, the 
timothy-hay bacillus, the butter bacillus, etc., are dissolved by 15 
per cent, of antiformin in thirty minutes. The human and the bovine 
types of tubercle bacilli were not affected with a 50 per cent, antifor- 
min solution for four days. Under the circumstances it appears that 
the pathogenic bacteria may be discovered with the aid of this method. 
It is, however, important that a fresh solution of antiformin should 
always be used, because a weak and old solution may leave the non- 
pathogenic bacteria and thus lead to error. 

Much's Granules. — As has already been stated, there are cases of 
pulmonary tuberculosis in which no acid-fast bacilli can be discovered 
in the sputum by any method, and Much has shown that they are 
due to a certain kind of bacilli which have lost their acid-fast property, 
but are Gram-positive and they retain their virulence. According to 
some authors these Much granules are almost always found in cases 
of fibroid phthisis, chronic bronchitis, emphysema, bronchiectasis, etc., 
in which acid-fast bacilli are very rarely discovered (see p. 18). Much 
found them in cases of cold abscess. 

As to the causes why the bacilli lose their acid-fast properties, there 
is no agreement. It also appears that the proportion of cases in which 
they are found varies with different observers, some having detected 
them in as many as one out of eight sputa, while others in less than 
2 per cent. Much gives several methods for staining these granules. 
The following is the most suitable: 

A very thin smear is made of the sputum and allowed to remain for 
twenty-four to forty-eight hours in a methyl-violet solution (methyl- 
violet, 10 c.c. of a saturated solution, in 100 c.c. of a 2 per cent, watery 
solution of carbolic acid) at 37° C. temperature; or it may be stained 
by boiling for a few minutes over the flame. Wash and stain for one 
to five minutes with Gram's iodine and put for one minute in a 5 per 
cent, nitric acid solution, then in a 3 per cent, hydrochloric acid 
solution for ten seconds, and finally complete the decolorization by 
placing it for a few seconds in acetone-alcohol (equal parts of acetone 
and alcohol). Wash and dry. 

Prognostic Value of Microscopic Findings. — The interest displayed by 
many patients, as well as by physicians, in the number of bacilli 
found in a specimen of sputum examined with a view of drawing prog- 



1 Centralbl. f. Bakteriol., 1915, lxxvi, 356. 



EXAMINATION OF THE SPUTUM 177 

nostic conclusions is unjustified. There are cases which show but few 
bacilli in each specimen, yet they run a very acute and progressive 
course, while others with numerous bacilli pursue a slow, chronic 
course, terminating in recovery. Especially is this seen in senile 
phthisis, in which the number of bacilli expectorated is enormous and 
we may, in fact, speak of pure cultures; yet these "bacilli carriers" 
live on for years with comparative comfort. Of course, in such cases 
we may deal with a small ulcerating cavity in the lung which offers 
good opportunities for the growth of bacilli, but the fibrous capsule 
prevents the extension of the lesion. 

The number of bacilli in the sputum fluctuates from day to day, 
evidently depending to some extent on the bit of sputum we happen 
to pick up with the loop. On the other hand, the complete absence 
of bacilli from the sputum for several weeks, coupled with improve- 
ment in the general condition of the patient, is undoubtedly a favor- 
able sign. But many chronic cases, especially fibroid phthisis, are 
always "closed" — bacilli are scanty or absent. With modern methods 
of antiformin examination of sputum the number of "closed" cases 
has been reduced very much. 

Inoculation. — In very suspicious cases in which a diagnosis is im- 
perative, but the microscopic findings are negative, inoculation of the 
sputum into guinea-pigs may clear up the case. The simplest way is 
to inject it subcutaneously by means of a hypodermic syringe; or a 
pocket is made by a small incision and the sputum introduced with 
a platinum loop. The best place is the abdomen. After three weeks 
the animal is examined for enlargement of the regional lymphatic 
glands. If these are not found enlarged, the guinea-pig is killed after 
waiting two months, and if suspicious areas are found at autopsy they 
are examined carefully. In most cases the regional lymph glands are 
enlarged in four or five weeks to the size of a pea and palpable. The 
animals may then be killed with chloroform with a view of more 
careful examination at the autospy. 

There are, however, on rare occasions cases in which it is of great 
importance to ascertain the presence or absence of tubercle bacilli in 
the sputum sooner than in six or eight weeks. Some have suggested 
that after the suspected material has been injected into the abdominal 
wall or the peritoneum, the animal should be tested at frequent inter- 
vals with tuberculin. A positive reaction clears up the case (Romer 
and Joseph 1 ). F. Gratz 2 has used the intracutaneous method. He 
inoculated 1000 guinea-pigs and then applied the intracutaneous tuber- 
culin test and found that in ten or twelve days after the inoculation 
of the infectious material a positive diagnosis may be made. Martin 
Jacoby and N. Meyer 3 suggest that the sputum be injected into a 
guinea-pig and about fourteen days later 0.5 c.c. of tuberculin should 
be injected subcutaneously. If the sputum contains tubercle bacilli 

1 Beitr. z. Klin. d. Tuberc, 1909, xiv, 1. 2 Ibid., 1916, xxxvi, 99. 

• 3 Ibid., 1911, xx, 263. 
12 



178 



COUGH AND EXPECTORATION 



and infects the animal, it will die from anaphylactic shock within a 
few hours. 

But these methods are not infallible. Selter 1 shows that a posi- 
tive reaction in an inoculated guinea-pig indicates that infection has 
taken place, while a negative result does not prove the contrary. 
The autopsy alone is conclusive. Many guinea-pigs inoculated by 
Selter with small doses of virulent bacilli were found to give negative 
results to the intracutaneous test, while the autopsy revealed marked 
tuberculous changes in various organs. 

It must also be mentioned in this connection that guinea-pigs are 
often tuberculous spontaneously. Many authors have reported that 
they found tuberculous lesions in these animals. Sir Almroth Wright, 
Frank J. Clemenger and F. C. Martley 2 point out that great difficulties 
are encountered in obtaining guinea-pigs free from pseudotuberculosis; 
a large proportion of the animals were found affected with various forms 
of this disease. In a lot purchased from a guinea-pig fancier who bred 
his animals exclusively for purposes of exhibition, and which were 
young and, from all outward appearances, perfectly healthy, a point 
was made to autopsy with great care, each of the animals of this lot 
that had been killed for the purposes of securing fresh serum for com- 
plement, and pseudotuberculous lesions were found in every one of 
them. "The amazing point about these infections with pseudotuber- 
culosis is the large amount of vital organs which can be involved in 
the local process, and yet permit the animals to live in apparent health." 
The possibility of error while utilizing guinea-pigs for diagnostic 
experiments is manifest. 

Elastic Fibers. — Before the discovery of the tubercle bacillus great 
stress was laid on the presence or absence of elastic tissue in the 
sputum in the diagnosis of tuberculosis, but of late this is only rarely 
looked for. It is, however, a simple thing to find elastic tissue when 
present in the expectoration, and it is of immense diagnostic signifi- 
cance because it can be found in over 90 per cent, of tuberculous sputa. 

The presence of elastic fibers in the sputum is an indication of 
destruction of lung tissue and it may be found in the very early stages 
of the disease, because chronic tuberculosis is a destructive process, 
and small excavations may be found quite early, and the elastic fibers 
are not destroyed during the caseous degeneration which liquefies the 
pulmonary tissue. It is also found in gangrene, abscess, syphilis, and 
infarction of the lung, so that when the latter can be excluded, it may 
greatly assist in the diagnosis of doubtful cases of tuberculosis. 

Technic. — A small amount of the thick, purulent portion of the 
sputum is pressed into a thin layer between two pieces of plain window- 
glass, 15 x 15 cm. and 10 x 10 cm. The particles of elastic tissue 
appear on a black background as grayish-yellow spots, and can be 
examined in situ under a low power. Or, the upper piece of glass is 






1 Deutsch. med. Wchnschr., 1916, xlji, 77, 283. 

2 Senate Document, No. 453, Washington, 1916. 



EXAMINATION OF THE SPUTUM 179 

slid off till the piece of tissue is uncovered, when it is picked out and 
examined on a slide, first with a low and then with a high power. 
(Simon.) 

A simpler method is the following: A bit of purulent sputum and 
a drop of 10 per cent, solution of sodium or potassium hydroxide are 
placed between a cover-glass and a slide and examined with a mod- 
erate power under the microscope. The elastic tissue is to be looked 
for especially at the border of the preparation. 

If the fibers are scanty they may not be found in this way, and the 
following method may reveal them: The sputum is boiled with a 
10 per cent, solution of KOH and well stirred during the boiling. 
When a homogeneous mixture is obtained, it is diluted with four times 
as much water, well shaken, and allowed to stand in a conical glass, 
or centrifuged. The sediment contains all the elastic tissue, which 
may be found under the microscope. 

The different methods of staining elastic tissue are not necessary 
because either of the above methods is sufficient for diagnostic purposes. 




Fig. 18. — Elastic fibeis in the sputum, (v. Jaksch.) 

Cytology of Sputum. — Various attempts have been made to assign 
diagnostic and prognostic significance to the cytology of tuberculous 
sputum, especially to the leukocytes and lymphocytes, but without 
avail. Nothing diagnostically important can be learned from a study 
of the white-blood cells in the sputum, so far as we know at present. 

Chemical Examination.— The chemistry of the sputum in pulmo- 
nary tuberculosis has not yielded any important diagnostic or prog- 
nostic data, excepting the albumin reaction which is of immense value 
in doubtful cases and is often of assistance when the microscope fails 
to reveal tubercle bacilli. Sputum with a positive albumin reaction 
can be found in tuberculosis and also in cases of pulmonary emphysema 
with cardiac dilatation, pneumonia, pleurisy with effusion, etc., but 
never in uncomplicated bronchitis. 

A positive albumin reaction is not always decisive of tuberculosis, 
but the negative outcome, when persistent during several examina- 



180 COUGH AND EXPECTORATION 

tions, undoubtedly excludes phthisis. 1 In some cases of advanced 
tuberculosis, especially fibroid phthisis, the albumin reaction is nega- 
tive, but in. such cases the diagnosis is only rarely a problem. It also 
appears that with the improvement in the condition of the average 
patient, the amount of albumin in the sputum decreases and finally 
it disappears. It is thus of prognostic value. 

Technic. — The albumin test is made as follows: A 3 per cent, solu- 
tion of acetic acid is added to the sputum, which is then thoroughly 
shaken. During ten or fifteen minutes the bottle is allowed to stand, 
and repeatedly shaken during this time. It will be observed that the 
mucus is coagulated by the acetic acid, and when it is then filtered 
through paper into a test-tube, the filtrate appears as a clear fluid. 
Occasionally all the mucus is not coagulated with the first attempt 
and this is easily ascertained by adding a drop of acetic acid to the 
filtrate, which in such cases again shows flocculi collecting as a pre- 
cipitate. The process is then repeated until a clear filtrate is obtained. 
The clear fluid is next boiled over a Bunsen burner or an alcohol lamp 
and while boiling some crystals of common salt, or a concentrated 
solution of sodium chloride are added. 

If albumin is 'present, there results a cloudiness, or a curdy precipi- 
tate which, on standing, settles to the bottom of the tube. Roughly 
speaking, the amount of the precipitate gives an idea of the amount 
of albumin present. The most important precaution to be observed 
is that nothing but a curdy precipitate should be considered as posi- 
tive, because the presence of mucus, which the acetic acid does not 
always completely dissolve, may also give a cloudy precipitate on 
boiling. But this reaction is not curdy, nor does it settle on standing. 
Of course, any other test for albumin may be used on the filtrate, but 
the above gives satisfactory results. 

1 Fishberg: Med. Press and Circular, 1912, xciv, 352; Arch, of Diag., 1912, v, 220. 






CHAPTER IX. 
FEVER AND NIGHTSWEATS. 

FEVER. 

Fever is one of the first symptoms of active phthisis — perhaps the 
first. It does not run a characteristic course in every case like that 
in malaria, pneumonia, or typhoid fever; in fact, its polymorphism is 
noteworthy. Yet it is of immense diagnostic and prognostic value. 
Some authors state that the fever in incipient tuberculosis is invari- 
ably due to some complication. But the febrile reaction after the 
administration of tuberculin, as well as acute miliary tuberculosis, 
shows clearly that this view is incorrect. All the available evidence 
combines to prove that it is due to absorption of the poisons produced 
by the tubercle bacilli, though it may be modified by mixed infections. 
The fever is engendered mainly by the increased production of heat — 
the result of complex biochemical processes having their origin in the 
struggle of the organism with the bacilli; the body summoning its 
defensive forces against the toxins produced by the decaying tissues. 
These latter stimulate the heat regulating center. In evaluating the 
significance of fever in tuberculosis, it must be borne in mind that 
it is not the cause of the disease, but a result of its activity. 

Fever is present in nearly all cases of active disease. In the later 
stages, especially in fibroid phthisis, we often meet with afebrile 
periods of shorter or longer duration, but with each exacerbation of the 
disease, with each extension of the process in the lungs, there is always 
a pronounced rise in the temperature which should be studied if the 
evolution of the case is to be followed. 

Thermometers. — The reason why there are found so many apyretic 
cases of phthisis is mainly faulty' technic in taking the temperature, 
especially defective thermometers. 

The clinical thermometer is an instrument of precision, and when 
used for the purpose of ascertaining the temperature in incipient 
phthisis, in which 1° is occasionally of immense importance in diag- 
nosis and prognosis, it must be accurate. It is, however, a well-known 
fact that, despite the certified accuracy of each instrument, simul- 
taneous observations made on a single patient with two instruments 
often disclose a difference in readings of 0.75° to 2°. The simultaneous 
immersion of two dozen thermometers in a bath of warm water dis- 
closed that the readings varied from 98.2° to 101.6° F.; another 
similar batch of higher- priced thermometers in another bath showed 



182 



FEVER AND NIGHTSWEATS 



variations of temperature between 98° and 105.4° F. 1 "Certified" 
thermometers in this country are not much better. Bray 2 reports 
that out of a series of 83 certified thermometers tested in a water- 
bath, 17 showed a variation of 0.3° to 0.6° F. Comparative rectal 
readings approximated closely the discrepancies shown in the water- 
bath. The presence or absence of fever, when such thermometers are 
used to ascertain it, depends on the instrument which the physician 
happens to possess and not at all on the condition of the patient. 
Under the circumstances, it is clear that when searching for fever in 
tuberculous patients or suspects, the instruments must be reliable and 
of tested accuracy, otherwise grave diagnostic mistakes of omission or 
commission are likely to occur. 

Technic of Taking the Temperature. — After having a good ther- 
mometer, we must exercise great care in the method of taking the tem- 
perature. I have been so often misled by readings taken in the axilla, 
sometimes finding it as much as 3° below that recorded in the rectum, 
that I now completely discard it. And, strange to say, I meet with 
no patients who refuse to take their temperature per rectum. It has 
been found that in some cases the temperature in the axilla is higher 
on the affected side and urged as a good sign of phthisis, but it is so 
rare that it may be disregarded. 

The mouth temperature is also unreliable to a certain extent. Here 
it is influenced by the temperature of the external air which must be 
inhaled now and then, especially by patients suffering from nasal 
obstruction. The part of the instrument outside the lips, and at times 
also the part within the mouth, are chilled by the external air, more 
often in dyspneic patients. The instrument must be left in the mouth 
at least seven minutes, and it often takes at least ten minutes before 
the mercury rises to the highest point, even with the so-called "minute 
thermometers." On the other hand, in patients suffering from stomat- 
itis, the local tempecature may be much higher than that of the blood. 
The temperature in the mouth should also not be taken immediately 
after meals, after taking hot or cold drinks, after washing the mouth 
or brushing the teeth, etc. Many patients are unable to keep the 
thermometer properly beneath the tongue, all surrounded by buccal 
mucous membrane, and avoid breathing through the mouth, or talking, 
for five to ten minutes. 

It appears that the majority of physicians in sanatoriums are in 
favor of oral readings because they are dealing with patients who 
practically always associate in groups and cannot use the rectal method 
unless they retire to their rooms for the purpose several times a day. 
This drawback does not hold with bed-ridden patients, and also with 
the average clientele in the city. In fact, I found that suspects, who 
keep at their work while under medical observation, prefer the rectal 
method which they take in the lavatory and thus obviate observation 

1 Lancet, October 4, 1913; November 8, 1913, p. 1342. 

2 Am. Jour. Med. Sc, 1915, cxlix, 838. 



FEVER 



183 



by others. In my hospital work also, there is no trouble in taking 
rectal temperature in walking patients. 

That the rectal method is superior and less likely to mislead is now 
acknowledged by all who have given both methods a trial. In the 
rectum or vagina the instrument is on all sides surrounded by mucous 
membrane, holding it in place as long as necessary and giving reliable 
readings. It has been found that the rectal is almost invariably 0.5° 
to 1° F. higher than the mouth temperature (Fig. 19). It is needless 
to add that the instrument is to be left in the rectum sufficiently 
long to obtain the maximum reading. In my instructions to patients 
and nurses, I tell them that I do not know of any one-minute ther- 
mometers, and all are to be left in situ at least five minutes. 

Frequency of Taking the Temperature. — The habit of many physi- 
cians of taking the temperature when the patient visits them and 
recording it as normal, or elevated to a certain degree, is altogether 




NOTE. FULL LINE= MOUTH. DOTTED LINE = RECTAL. 

Fig. 19. — Comparative oral and rectal readings of temperature. (Bray.) 



wrong. In incipient, or doubtful, cases taking three readings a day may 
be misleading, at times, because rises in temperature which occur late 
at night, or early in the afternoon, and are short-lived, may thus be 
overlooked and the patient pronounced free from fever. For reasons 
which will soon be evident, we must, in incipient cases, have a record 
of the temperature taken every two hours, and this is best recorded by 
plotting a curve on a chart which shows graphically any hypothermia 
or hyperthermia. 

Intelligent patients may be entrusted with a thermometer, provided 
they are trained in reading it correctly, which can be done in a few 
minutes. I have had patients who kept records of their two-hourly 
temperature for weeks and, for obvious reasons, more conscientiously 
than the average nurse. Many have done it without leaving their 
occupations by simply going to the lavatory every two hours for five 
minutes. 



184 



FEVER AND NIGHTSWEATS 



The Normal Temperature.— It may be stated that the normal 
temperature in children is not a constant value. It is subject to such 
oscillations during perfect health, that any average which has been 
fixed by various authors is only arbitrary. The slightest disturbance 
in health is likely to increase the temperature in the child to a greater 
degree than in the adult. Many clinicians consider a temperature 
of 100° to 101° F. normal in a child, unless there are symptoms of 
disease. But with advancing age the temperature becomes more and 
more settled, so that in adults it is subject to lesser oscillations, unless 
raised or depressed by disease. 

As an arbitrary guide for the clinician it may be taken that a tem- 
perature of 98.6° F. when taken by mouth, and 0.5° higher when taken 
by the rectum, is normal. But even this shows striking diurnal varia- 
tions in normal individuals. During the early morning hours, before 
the individual leaves his bed, it is slightly subnormal from 0.5° to 1°; 
but it rises to normal soon after rising, and keeps quite steady during 



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Fig. 20. — Fever in incipient tuberculosis showing marked subnormal temperature 
in the early morning hours. Temperature taken twice daily. 

the day. Bardswell and Chapman 1 found an average for waking hours 
98.5° F., and for sleeping hours 97.2° F., taken by mouth, which is in 
agreement with the observations of most physicians. 

There are, however, individuals in whom the temperature is lower than 
the above average and in whom a physiological normal temperature should 
be considered febrile. This is occasionally seen in tuberculous patients 
with subnormal temperature; when the thermometer registers 99° F. 
they present symptoms of fever, such as flushing, hot skin, headache, 
etc. 

Normally the temperature is elevated in persons after exercise, and 
in some even after a hearty meal. In women it may be higher by 1° or 
2° before, or during menstruation. But the elevation after exercise 
is, in the healthy individual, evanescent; within one-half to one hour 
it sinks again to normal. 



British Med. Jour., 1911, i, 1106. 



FEVER 185 

Other influences which should be mentioned are the emotional 
states of the individual. Particularly in women, excitement may raise 
the temperature 1° to 2°. Where there is a question of tuberculosis, 
the excitement attending the taking of the temperature may be effective 
in raising it, as I have seen in several cases, and we must be very 
careful in making a diagnosis of incipient phthisis on the thermometrical 
readings alone in emotional women. 

In some people who work during the night, and sleep during the 
day, the variations in temperature mentioned above are said to be 
reversed. 

In evaluating thermometrical findings in suspected incipient phthisis, 
we are on safe ground when we consider the normal temperature during 
the day in a person who works, or walks around, as 99° F., when 
taken per rectum, and 0.5° to 0.75° lower when taken by mouth. It 
may be 0.5° to 1° lower in the morning before rising, and 0.5° higher 
in the evening after a heavy meal, or after a hard day's work. Dis- 
tinct variations from these figures demand explanation, and if no 
other cause is found, tuberculosis is to be considered as the possible 
cause. 

Fever in the Incipient Stage. — When taken with due precautions 
it will be fotmd that a subjebrile or febrile temperature is characteristic 
of the evolution of active phthisis even in the incipient stage, and that the 
absence of fever excludes active disease. The afebrile cases of phthisis 
mentioned by physicians are mostly the result of faulty teclmic in 
taking the temperature. Evanescent rises are overlooked. Moreover, 
in these cases the instability of the temperature could be determined 
by ordering the patient to take some exercise. An elevation of 0.5° 
to 1.5° in the afternoon, or after some excitement, or exertion, lasting 
about half an hour may be observed in some persons who have no 
tuberculosis, as was mentioned above; with the phthisical, however, 
it is more lasting. It appears that a large proportion of patients with 
early tuberculosis have a subnormal temperature in the early moroing 
hours, some recording as low as 96° F.. before getting out of bed. 

When interpreting fever in the early stages of phthisis, we should 
follow Daremberg's 1 suggestion and consider the difference between 
the highest and lowest temperature. Thus, a patient with a tempera- 
ture of 99.8° F. at 5 p.m. has not only 1° above normal when his morn- 
ing temperture is 96.5° F., but 3.3° above normal, and should be con- 
sidered febrile, and when persisting for some time, it is undoubtedly of 
tuberculous origin, unless some other cause is foimd. 

Symptoms of Fever.— These afternoon rises can also be distin- 
guished from other rises, and from physiological elevations, by the 
concomitant symptoms which are met with in most cases of incipient 
phthisis. In the latter there is an acceleration of the pulse-rate far 
out of proportion to the slight elevation of temperature. Many also 

1 Tuberculose Pulmonaire, Paris, 1905, p. 59. 



186 



FEVER AND NIGHT SWEATS 





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FEVER 187 

have mild chilly sensations, or even a distinct chill, about an hour 
before the rise in temperature, when the face is pale and the extremities 
feel cold. Later the face becomes flushed, the eyes brighten with 
characteristic brilliancy, which can often be recognized by the experi- 
enced observer, and the patient feels warm or hot, tired, fatigued and 
disinclined to work, and has some headache. It is noteworthy that, 
despite all these symptoms, the appetite for the evening meal is not 
diminished, which is not, as a rule, observed in fever due to other 
causes. Anorexia is a constant accompaniment of j ever, excepting the 
fever of early phthisis. This tolerance of fever by the tuberculous mani- 
fests itself also in their aptitude to work during the day and sleep 
during the night as if they were well, feeling only somewhat tired or 
languid, when the thermometer reads 101° F., or more. Finally, 
during the night more or less sweating may occur, which even in early 
cases may be so profuse as to drench the patient. 

Subjective Fever without Elevation of Temperature. — These symptoms, 
in varying degrees of severity, are only rarely absent in incipient 
phthisis, and they are excellent guides in our attempts at excluding 
rises in temperature due to other causes. In fact, the afternoon languor 
just mentioned is so characteristic of the toxic state of the tuber- 
culous that we often meet it in some advanced cases — notably, fibroid 
phthisis — which are afebrile. In such cases we may speak of subjective 
fever without elevation of temperature, first described by Dettweiler. 
I have seen it in a few cases of incipient tuberculosis. For this reason 
we must not rely solely on thermometry while treating tuberculous 
patients. Conversely, fever without subjective symptoms is occasion- 
ally, though very rarely, seen in incipient cases and the prognosis is 
very good indeed. 

Provoked Fever. — The heat center is apparently easily disturbed 
in phthisis and as a result we have usually a labile, or unstable, tem- 
perature. Conditions which in the average normal individual have 
no effect on the temperature may elevate it in the consumptive. Thus, 
a heavy meal, moderate exertion, emotional disturbances like reading 
or writing a letter, worn', anxiety, and excitement, especially during 
the early morning hours, may raise the temperature from 1.5° to 3° F. 
and more. I have seen the excitement of a medical examination raise 
the temperature of a patient in my office 3.5° within one-half hour, and 
in European sanatorium s it is a routine measure to inject water at 
the beginning of a course of tuberculin treatment with a view of ascer- 
taining whether the febrile reaction is really due to the tuberculin or 
to emotional disturbances. On visiting days in sanatoriums a large 
proportion of patients have higher fever than on other days. It has 
also been observed that a change in residence, as the admission into 
an institution, a railway journey, giving a sanatorium patient leave 
to spend a day with his family, etc., may elevate the temperature of 
the consumptive. 

This fievre provoquee, first described by Daremberg, and then again 



188 



FEVER AND~NIGfITSWEATS 



by Penzoldt, 1 can be utilized for diagnostic purposes in cases sus- 
pected of incipient phthisis. When we have a patient presenting 
indefinite symptoms and signs of tuberculosis, but the temperature 
is normal, we may take the temperature before and after active exer- 
cise, and if it is raised 1° F. or more, we are probably dealing with a 
case of incipient tuberculosis. The usual rule is to let the patient 
walk about two miles and note the effect. My way has been to ask the 
patient to take his rectal temperature before he starts out for my 
office, and then walk one and a half or two miles while coming. Im- 
mediately on his arrival his temperature is again taken, preferably 
with the same thermometer. 

A rise of 1° or more in the temperature after such a test is highly 
suggestive of tuberculosis; Daremberg insists that it is conclusive. 
Combined with other symptoms and signs, it is undoubtedly of great 
value. But in obese persons this may be observed without any tuber- 
culous lesions in their lungs and the same is true of anemic, especially 





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Fig. 22. — Female, aged nineteen years. Premenstrual fever in an afebrile case of 
incipient tuberculosis. (Bray.) 



chlorotic young women. But in physiological rises after exercise the 
elevated temperature again sinks to normal within half an hour of 
rest, while in the tuberculous it lasts much longer, two hours, or even 
more. 

Menstrual Fever. — In women the fever may be more accentuated 
during the menstrual period, which at times is of diagnostic importance 
(Fig. 22) . We must, however, remember that in many non-tuberculous 
women slight elevations of temperature are observed a few days before 
or during that period. But in the phthisical we meet not only with 
elevation of temperature, but occasionally also with an increase in the 
number of rales over the site of the lesion, hemoptysis, and pleuritic 
pains. Macht 2 says that "the rise in temperature may occur in afebrile 
patients, that is, patients who ordinarily run no fever, as well as in 
those who run a slight temperature throughout the month. These 

1 Handbuch der Therapie, Jena, 1910, iii, 188. 

2 Am. Jour. Med. Sc, 1910, cxl, 835. 



FEVER 189 

rises may occur in early cases as well as in advanced and in the former 
are of considerable diagnostic importance. If a patient shows a con- 
stantly recurring menstrual rise in temperature, and pelvic disease 
cannot be found, a tuberculous process should alwavs be borne in 
mind." 

In most cases the fever declines with the appearance of the flow; 
it may last several days, or only a few hours. Sabourin 1 has shown that 
in certain women the menstrual fever lasts three weeks and leaves the 
patient only one week before the onset of the next menstruation. Iu 
these cases it is of grave importance; the patients "are killed by their 
courses," as Sabourin says. 

Many authors, notably Vandervelde, Sabourin, Wiese, 2 C. A. Welch, 3 
E. C. Morland, 4 and others, state that premenstrual fever indicates 
latent or active tuberculosis and should be given attention when 
attempting to make a diagnosis in doubtful cases. This premenstrual 
fever occurs a few days before the onset of menstruation and may 
continue throughout the days of the flow. Considering that it has been 
found that in from 40 to 50 per cent, of tuberculous women there is 
hyperthermia before and during that period, while in healthy women 
the percentage is considerably less, these authors maintain that it is of 
immense diagnostic value, and that the absence of menstrual fever 
excludes active tuberculosis. 

According to Macht, these rises in temperature, when reaching 
high, are an evil omen prognostically; on the other hand, if they grow 
less, or disappear altogether, it is a sign of a cured, or an arrested 
condition. 

Evaluation of Fever in Tuberculosis. — In the usual case of chronic 
phthisis in the incipient stage there is a subfebrile temperature which 
is often overlooked, unless the thermometer is used every two hours 
for a week or two. The feeling of languor which overtakes the patient 
during the afternoon is often taken as an indication of neurasthenia, 
the anorexia is attributed to dyspepsia, and the real cause overlooked. 
From Fig. 23 it will be seen that if in this case the temperature had 
been taken only at 8 a.m., 12 m., and 8 p.m., as is usually done, the 
febrile reaction at three to six would have been overlooked, and the 
patient pronounced afebrile. In rare cases, these febrile reactions occur 
during the night and thus escape detection. Still rarer is the so-called 
"reversed type" of fever, the febrile reaction occurring during the early 
morning hours. It appears that the prognosis is unfavorable in the 
last class of cases. 

Since a subfebrile temperature for one or two days is no conclusive 
proof of the existence of active phthisis, because such ephemeral 
hyperthermia may be due to other causes, and also because there 
are afebrile days during the incipient stage of phthisis, the temperature 

1 Rev. de med., 1905, xxv, 175. 

2 Beitr. z. Klin. d. Tuberk., 1912, xxvi, 335. 

3 Lancet, 1910, i, 639. 4 Ibid., 821. 



190 



FEVER AND NIGHTSWEATS 



should be taken continuously for two or three weeks in doubtful cases 
before arriving at a conclusion. The readings thus plotted on the 
chart are the best graphic criteria for diagnosis. 

The slight afternoon rises in temperature characteristic of incipient 
phthisis are not exclusively met with in this disease; there are other 
conditions which may produce hyperthermia for weeks, greatly sim- 
ulating phthisis. For this reason we must not hastily decide in favor 
of this disease unless there are other symptoms and signs of lung 
disease. I have had under my care a woman who was treated for 
several months in a sanatorium, then handed over to surgeons for opera- 
tion for gall-stones, and while convalescing after the operation another 
diagnosis of tuberculosis was made. The woman was then admitted 
to the hospital under my care and for three months the afternoon 
temperature was almost invariably elevated 1° to 3°. We finally gave 
her work as a nurse and she worked during the succeeding six months 






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Fig. 23. — Incipient phthisis, active lesions in left apex. Temperature taken every 
three hours (black line) shows daily exacerbations of the fever reaching 102° F. in the 
afternoon. This exacerbation would be missed if temperature was only taken three 
times a day, at 8 a.m., 12 m., and 7 p.m., as is shown by dotted curve. 



quite hard and has not developed phthisis, nor shown any indications 
of the disease on physical exploration of the chest. She still has an 
elevated temperature every afternoon. These afternoon rises in tem- 
perature, when not due to tuberculosis, are mainly found in women. 
Anemia, especially chlorosis, and occasionally pernicious anemia, may 
be the cause. However, an examination of the blood clears up the case. 
Purulent conditions of the nose and accessory sinuses, chronic inflam- 
matory conditions of the tonsils, non-tuberculous bronchiectasis, 
pyelitis, diseases of the female genitalia, cirrhosis of the liver, Hodgkin's 
disease, pernicious anemia, leukemia, malignant neoplasm of the lungs, 
etc., may be accompanied by subfebrile temperature. These are but a 
few of the conditions which must be looked for in doubtful cases. 

After all, purely hysterical fever must be b}rne in mind when 
everything else has been ruled out. There is no question but that it 
does occur, although our modern views of the pathogenesis of fever 



FEVER 



191 



are against it. This appears to be one of the many paradoxes in 
clinical medicine. 

In evaluating the significance of the temperature range in active 
phthisis, we may be guided by the rules laid down by Harris and Beale i 1 
The higher the day temperature, the more active the disease, except 
in a few rare instances (the so-called "reverse type") where the ordi- 
nary fluctuations are reversed, and the night temperature remains 
lowest throughout the whole course of the disease. But whether the 
normal or the inverted remissions take place, the lowest temperature 
is always high, and so long as it follows this course, it may be assumed 
that active deposition of tubercle is taking place, even though the 
physical signs remain for the time unaltered. 

Most patients with fever lose in weight, but there are many excep- 
tions, and patients as well as physicians are apt to judge a case more 
by the scale than by the thermometer. This is wrong. There are cases 
of phthisis, especially those in whom the fastigium occurs during the 
night, that remain stationary or gain in weight, while the process in 
the lungs keeps on progressing. In other words, neither fever nor 



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Fig. 24. — Fever in incipient tuberculosis. Temperature taken every three hours. 

the weight alone should be taken as a criterion for prognosis, but all 
the concomitant symptoms and signs should be considered in this 
connection. 

On the other hand, the absence of pyrexia, while a good sign iu 
most cases, is not conclusive evidence of the mildness of the process, 
especially when other symptoms of active disease are present. I 
have seen many patients in whom the temperature never exceeded 
101° F., or was even less, still the anorexia, emaciation, cough, hemop- 
tysis, etc., were all active in bringing them to a fatal termination. 
This is especially seen in cases which have lasted for some years. The 
organism has adapted itself to the disease and does not react any 
more to the same degree that it does usually, and its defensive forces 
are in abeyance. It may be observed in patients with any lesion, not 
excluding those with large, but usually dry, cavities in the lungs. 

Types of Fever in Chronic Tuberculosis. — In progressive and also 
in advanced cases of phthisis the fever is not typical, and a diagnosis 

1 Treatment of Pulmonary Consumption, Loridon, 1895, p. 314. 



192 



FEVER AND NIGHTSWEATS 



cannot be made from an analysis of the temperature curve alone, as 
is often the case in malaria, relapsing fever, typhoid, pneumonia, etc. 
In phthisis we may meet with any type of hyperthermia in different 
patients, and in the same patient at different times, depending on the 
activity of the process, mixed infection with pyogenic organisms, soft- 
ening of lung tissue, free drainage of necrotic foci, etc. Under the 
circumstances we cannot speak of a typical tuberculous fever, but we 
meet with certain temperature curves which serve as good and reliable 
guides in our attempts at ascertaining the condition of the patient, 
the presence or absence of complications, and especially when attempt- 
ing to formulate a prognosis. 

Continuous Fever. — This is met with especially in cases with exten- 
sive pneumonic involvement, in acute pneumonic phthisis, and in 
tuberculous bronchopneumonia in children. In chronic phthisis which 
has pursued a favorable course, w T hen a continuous temperature 



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Fig. 25. — High, continuous fever in the terminal stages of pulmonary tuberculosis. 

develops after a pulmonary hemorrhage, or without any visible cause, 
we may conclude that there has occurred an extension of the process 
in the lungs; and if this high, continuous temperature — even when it 
does not exceed 103° F. — lasts more than three or four weeks, the 
prognosis is very grave and a fatal issue may be looked for. In some 
cases a slight improvement may occur, but it is noteworthy that they 
are never cured. 

Cyclic Fever. — In many cases of chronic phthisis we meet cyclic or 
undulating types of hyperthermia. The patient is never free from 
fever, but for two or three days during the week the maximum reading 
reaches 102.5° or 103.5° F., or even more, while the other four or five 
days it is much lower — 100.5° to 101.5° F. These wave-like fluctua- 
tions may appear more or less periodically for months and not only 
show variations during each week, but the febrile waves may appear 
at greater intervals, every two or three or four weeks, as can be seen 
from Fig. 26. It is seen in cases in which old foci are softening, or the 



FEVER 



193 



pulmonary process is extending, and 
each exacerbation of the fever is an 
expression of a new area of involve- 
ment which may, in many cases, be 
easily discerned by a careful physical 
exploration of the chest. 

Hectic Fever. — In progressive disease 
these types of hyperthermia are usually 
followed at the end by hectic fever 
(Fig. 27). In cases in which there is 
softening in the lung, the necrotic tissue 
being gradually expelled leaving cav- 
ities, the temperature chart tells the 
story. There are morning remissions 
during which the temperature is nearly 
normal, or even subnormal, while in 
the afternoon there may be a chilly 
sensation, or a distinct chill, with chat- 
tering of the teeth; the pulse, which 
was rapid and small during the apyrexial 
morning hours, is even more acceler- 
ated, the temperature begins to rise, 
reaching 103°, and in some cases even 
105° at about five in the afternoon. 
The nightsweats in these cases are very 
profuse and exhausting. 

The time of the highest fever in these 
hectic cases is variable. Often the 
maximum is attained in the afternoon, 
but in many it is around noon, and in 
the evening it may be normal. If in 
such cases it is taken only mornings 
and evenings, we may find a record 
of normal temperature, because the 
midday rise, which may have been 
quite high, has been overlooked. 

This hectic fever may last for weeks, 
or even for months, during which time 
the unfortunate patient is reduced to 
a skeleton by the fever and the ac- 
companying anorexia and diarrhea, 
which are hardly ever lacking. The 
frightful appearance of the bundle of 
bones with hardly any visible muscles, 
which have atrophied extremely, cov- 
ered by a clammy, muddy skin; the 
skin emaciated but edematous around 
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FEVER AND NIGHTSWEATS 



the ankles and knees, the eyes deeply set in the orbits, the temples 
sunken, are disheartening to the physician making his rounds in the 
hospital; he feels helpless when the slowly sinking, but still strug- 
gling, human being gazes, appealing for assistance which cannot be 



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Fig. 27. — Hectic fever in advanced cavitary phthisis. 




Fig. 28. — Irregular fever in advanced tuberculosis of the lungs with intestinal 

complications.- 



given. It is noteworthy that with all this material decay the intelli- 
gence, and often the hopes and aspirations of the patient, are well 
retained, and he begs for the relief of some minor, and comparatively 
insignificant symptom, such as the cough or diarrhea, saying that if 
this is removed he will feel in excellent condition. 

At the terminal stages there may be irregular fever; the curve of 
one day differs from that of the other. Saugman 1 states that this is 

1 In Brauer, Schroder, and Blumenfeld's Handbuch der Tuberkulose, ii, 284. 



FEVER 195 

a good sign of intestinal tuberculosis when occurring in the earlier 
stages of the disease (Fig. 28). 

Subnormal Temperature. — The subnormal temperature seen in many 
incipient cases during the morning hours has already been mentioned. 
But we also meet with patients in the advanced stages of the disease 
who present subnoimal temperature throughout the day and night 
for weeks; the mercury never rises above 98.5° F., and early in the 
day it may be as low as 96° or 97° F. The disease may be active and 
even progressive, yet the thermometer gives no indication of it. I 
have many of these cases in my hospital service. I find it is usually 
an indication of excavation, just as fever is an indication of infiltration, 
caseation, and softening of lung tissues. 

These cases have been recently spoken of by O. K. Stone: 1 "At 
certain periods of the disease, usually succeeding the active febrile 
stage, there is often a period when the temperature curve shows marked 
excursions in the subnormal, the temperature at no time rising above 
98.6° and rarely fully reaching this point. The patients during this 
period of subnormal temperature are usually improving and making 
distinct gains, but it takes very little to give them febrile exacerba- 
tions, lasting for a few hours to a few days." 

Subnormal temperature is also seen in fibroid phthisis, and in 
emphysema complicated by tuberculosis, in both of which the disease 
runs a chronic, sluggish course. Many keep disabled for years, though 
not confined to bed, but they never fully recover. A subnormal tem- 
perature is also seen on rare occasions in a subacute case of phthisis 
which suddenly took a turn for the better after the necrotic tissue in 
the lung had been eliminated from that organ and a cavity remained . 
In this class recovery may take place, as I have seen on several 
occasions. 

The sudden drop in the temperature, combined with dyspnea and 
cyanosis, in a febrile case of phthisis may mean a spontaneous pneumo- 
thorax, or a rapid extension of the necrotic process in the lung over- 
whelming the patient. The prognosis in either event is grave indeed. 
In many extremely emaciated consumptives the temperature is at 
times subnormal for several days before death. 

Apyretic Tuberculosis. — In old chronic cases of phthisis we may 
have a normal temperature for months, though the process in the 
lungs keeps up. This is seen in fibroid phthisis, in phthisis in the aged, 
and in tuberculous pleurisy. Many of these patients live for years and 
do not lose in weight. I have seen such patients last for fifteen and 
twenty years, always ailing, coughing, expectorating, at times hav- 
ing spells of more or less profuse hemoptysis. They are important 
sources of the dissemination of tubercle bacilli; more so than most 
of the stormy cases. They are not strong enough for muscular work 
but may be moderately efficient at any occupation which does not 

Boston Med. and Surg. Jour., 1914, clxxi, 1008. 



196 FEVER AND NIGHTSWEATS 

require undue exertion. We meet these cases mainly among the well- 
to-do, who can afford to lead an idle life, or among the very poor who 
have intrenched themselves in hospitals for chronic and "incurable" 
cases of tuberculosis and, for one reason or another, like institutional 
life, and stick to it for long periods. We also meet these active, but 
apyretic, cases among the more cultured classes, who either know how 
to take care of themselves or, being professional persons, they may 
pursue their vocations with more or less efficiency. Some are very 
brilliant, and the type or consumptive drawn by so many writers of 
fiction is usually copied after the model of this class of patients. It 
is noteworthy that while most of them are more or less emaciated , we 
now and then meet one who is actually fat and may even be placed 
in the category of the obese. They usually suffer from dyspnea, 
because of the fatty heart and pulmonary fibrosis. 

Phthisis in the aged also runs an apyretic course at times and, because 
they do not cough excessively, the disease may not be recognized. 

It appears that there are great differences in the reactive powers 
of different persons suffering from phthisis. In some the fact that 
they have a normal temperature is no proof that the disease is benign, 
especially if other symptoms of active disease are present. I have 
seen patients whose temperatures hardly ever exceeded 101° F., yet 
they wasted, perspired, and had exhausting diarrhea; they finally 
died with a low temperature. While the temperature curve is an 
excellent guide as to the tendencies and progress of the disease, these 
apyretic cases must be judged more by the general symptoms and the 
physical signs than by the thermometrical findings, as has already 
been shown. 

Fever due to Complications. — During the course of phthisis fluctua- 
tions in the temperature usually go hand-in-hand with the activity 
of the disease, and each elevation or depression in the temperature 
curve may be explained by the findings in the chest through physical 
exploration. But there are exceptions. Many elevations of the tem- 
perature are due to non-tuberculous complications. Thus, as will 
be seen from Fig. 29, malaria may complicate phthisis and produce 
confusion, unless the blood is examined and the malarial parasite is 
found. 

Other complications to be mentioned are constipation, acute gas- 
tritis, tonsillitis, influenza, pleural effusions, etc. These may be the 
cause of a sudden elevation of temperature in a case in which the 
tuberculous process is proceeding rather favorably. Careful examina- 
tion usually reveals the cause of the pyrexia. 

A rise in the temperature in a tuberculous patient may be due to 
the administration of certain drugs, mostly of the sedative and hyp- 
notic class, as has been pointed out by Sabourin 1 and Mantoux. 2 I 
have repeatedly observed that after the administration of opium, or its 

1 Rev. gen. de clin. et de therap., 1906, xx, 639. 

2 Rev. de la tuberc, 1907, iv, 395. 



FEVER 



197 



derivatives, morphin, codein, heroin, dionin, etc., or chloral, veronal, 
snlfonal, trional, etc., there is often a rise in the temperature during the 
succeeding twenty-four hours. A rise of this kind is especially vivid 
when occurring in an afebrile patient to whom one of these drugs has 
been administered. The fever lasts no more than twenty-four hours, 
as a rule, but I have seen cases in which it lasted longer. Hypodermic 
medication is more apt to act this way, and Mantoux says that injec- 
tions of salt solution may also elevate the temperature. 

Diagnostic and Prognostic Significance of Fever in Phthisis. — Sum- 
marizing the results obtained in this section, we may say that in a 
patient ivho shows a distinct elevation of temperature during the afternoon 
for several iceeks, and no other cause can be found, tuberculosis is to be 



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Fig. 29. — Malaria complicating phthisis. 



thought of. If it is provoked by moderate exercise, and persists after 
more than an hour of rest, it i? almost pathognomonic of phthisis. If 
with it there are other symptoms, such as nightsweats, anemia, loss 
of weight, cough, emaciation, etc., tuberculosis is in all probability 
the cause, even if the physical signs are not definite. The diagnosis is 
more certain if the morning temperature is subnormal. 

In the course of the disease a high temperature during the day, never 
touching the normal, and ascending in the evening is an indication of 
progressive activity of the process in the lung. The disease is progressing 
slowly, or is even quiescent, w T hen the temperature in the early morn- 
ing on rising is subnormal or normal and remains so during the day, not 
rising above 101° F. late in the afternoon or evening. 



198 FEVER AND NIGHTSWEATS 

High, continuous temperature, above 103° F., is an indication of 
extension or dissemination of the disease in the lung, and if it lasts for 
more than a month, a fatal issue is to be expected; even if some 
improvement is noted, recovery should not be expected. 

Hectic fever, with normal or subnormal temperature in the morning, 
and high fever, 103° or more at midday or later, is an ill omen. While the 
patient may keep on in this condition for weeks or months, he will in 
all probability never leave his bed alive. 

In most cases, absence of fever is an indication of an improvement or 
a cure of the disease, but there are many exceptions, and the other con- 
stitutional symptoms must be considered when formulating a prognosis. 
A subnormal temperature, when coming on suddenly, is a bad sign. 
When chronic, lasting for several weeks, however, it is not incompatible 
with an inactive, though not necessarily an inefficient, life. 

NIGHTSWEATS. 

Nightsweats have at all times been considered pathognomonic of 
phthisis. A prolonged cough will not alarm the average person, but 
when it is associated with nightsweats, he will soon consult a physician 
with a view of ascertaining whether or not he is tuberculous. They 
are met with quite early in the disease in many cases; at times when 
the characteristic symptoms and physical signs are lacking, but in 
advanced cases their severity does not depend altogether on the extent 
of the lesion. 

Causes. — The causes of nightsweats are obscure Some have attrib- 
uted this phenomenon to the compensatory activity of the skin when 
the pulmonary respiratory area is diminished, but we meet them in 
cases with but little damage to the lung. Gustav Heim 1 is of the opinion 
that the products of cell disintegration, and especially the toxins pro- 
duced by the bacilli, stimulate the sweat center directly or reflexly, 
just as after childbirth the remains of the placenta may produce 
sweating. It is an attempt on the part of the body to rid itself of 
harmful matter, as it is excreting carbon dioxide in the sweat when this 
is excessive in the blood. Smith and Brehmer have attributed the night- 
sweats to the quick change of the tachycardia of the day to the brady- 
cardia of the night. Because stimulating food, like milk punches, 
often prevent nightsweats, they find therein a confirmation of their 
theory. 

It appears that Cornet's theory is more in harmony with the facts 
observed clinically. He looks upon nightsweats as due to the absorp- 
tion of the proteins of the tubercle bacilli and other microorganisms ' 
secondarily implanted in phthisical lesions. The toxins are absorbed 
into the blood stream and they stimulate the heat center, thus causing 
fever; and also act upon the sweat center in the cord and medulla 

1 Ztsckr. f. Tuberk., 1910, xvi, 365. 



NIGHTSWEATS 199 

and the peripheral secretory glands and thus produce perspiration. He 
shows that this also confirms the fact that, in spite of the great dis- 
tuibance, the diminished excretion of fluid, and the greater difficulty 
in the elimination of carbon dioxide which is characteristic of the 
chronic course of the disease as compared with acute phthisis, the 
secretion of sweat is incomparably less in the former, owing solely to 
the more gradual absorption of the toxins. 

Symptomatology. — Nightsweats usually occur in the second part of 
the night, about 2 to 4 a.m., in typical cases. The patient retires with 
some fever, and in hectic cases may have had a chill on the preceding 
afternoon, sleeps rather restlessly, is disturbed by dreams or by cough, 
and wakes up during the early morning hours drenched with perspira- 
tion. At times, changing the night- and bedclothes may prevent their 
recurrence during the same night, but in many cases this is of no avail, 
as the sweats again trouble the unfortunate victim. 

In the milder forms, the sweating may be local, on the forehead, 
the neck, the chest, etc. Rarely it is noted on only one side of the body, 
usually the one corresponding to the pulmonary lesion. 

In the progressive and hectic cases the sweating may be so profuse 
and drenching as to exhaust the patient who often begs for the relief 
of this symptom alone which, together with the diarrhea, is instru- 
mental in relieving him permanently from his earthly sufferings. 

It is important to mention that the nightsweats do not directly harm 
the patient, considering that only 1 per cent, of solids is eliminated in 
this way, of which 0.7 per cent, is salts, mainly uric acid. Only so far 
as disturbing sleep is concerned are nightsweats harmful. In children 
their diagnostic significance is less than in adults. (See Chapter 
XXIV.) 

In some cases the disease runs its course without any, or only with 
slight nightsweats. Kuthy found that 37 per cent, of his patients had 
nightsweats during the first stage of the disease. In the third stage, 
61.5 per cent. According to this author, women are more apt to sweat 
profusely than men. But Louis found only 10 per cent, of cases with- 
out nightsweats, and at the Phipps Institute they were absent in 41 
per cent, of 3344 cases. 

In the evolution of phthisis it is observed that the sweats run hand- 
in-hand with the fever and the general condition of the patient. During 
afebrile periods they are absent to return with an acute exacerbation. 
There are said to have been observed cases of nightsweats without 
fever, but my experience leads me to believe that the fever was over- 
looked in such cases. One of the best signs of improvement is the 
complete disappearance of the nightsweats. 

Nightsweats may be prevented in a large proportion of cases by 
the adoption of hygienic bedding and coverings during sleep, as will 
be shown in another part of this book. 

Sweating appears to be easily provoked in the phthisical. Kuthy 
and Wolff-Eisner say that not only consumptives, but also those 



200 FEVER AND NIGHT SWEATS 

" predisposed" sweat easily, who, when waking, find themselves bathed 
more or less in perspiration. Mild exertion, grief, worry, excitement, 
etc., may be followed by more or less profuse perspiration, general or 
local. In a large proportion of patients we see sweating in the armpits 
during medical examination, even in patients who do not sweat during 
the night. We also meet with patients who sweat during the day while 
taking a nap, etc. 

While most authors, notably Cornet, state that the sweat does not 
carry infection, recent investigations by Piery have shown that it may 
contain bacilli which are pathogenic to animals. Salters showed that 
hypodermic injections of the sweat into animals act like tuberculin. 



CHAPTER X. 
HEMOPTYSIS. 

Frequency. — To the layman the most reliable symptom of pul- 
monary tuberculosis is blood-spitting and many physicians share this 
view, although we know that a large proportion of cases of phthisis 
pursue their course and terminate in recovery, or fatally, without any 
hemoptysis, while in many patients hemoptysis is not due to tuber- 
culosis. The statistics of the frequency of this symptom vary con- 
siderably, some finding it in but 25 per cent., while others report as 
many as 80 per cent, having had hemorrhages during the course of 
phthisis. Sokolowski says that advanced consumptives who did not 
bleed from time to time are only rarely met with. Louis found this 
symptom in 65 per cent, of cases; Walshe 1 in 80 per cent.; Wilson 
Fox 2 says that more than one-half of all cases of phthisis present this 
symptom in some part of their course; Williams found it in 70 per cent. ; 
Sorgo 3 in 38 per cent., Condie in only 24 per cent.; Elmer H. Funk 
among 373 patients with advanced disease, in 44 per cent.; among 
167 patients traced to the end in 54 per cent., and at the Phipps 
Institute at Philadelphia, it was found in 49.9 per cent, of 4466 
tuberculous patients. 

These wide differences in the percentages are easily explained by the 
fact that the authors have not taken their figures from comparable 
material. Some have spoken only of fatal cases, others of cases in their 
private practice, while still others have taken hospital records as their 
criteria. In the latter classes the patients were observed only for a 
short time, and hemorrhages which may have taken place later have not 
been considered. 

Anders 4 found in a series of 5302 cases that 36.6 per cent, had hemop- 
tysis. He emphasizes, however, that not all were followed until the 
death or recovery of the patients, but many were discharged during 
the course of the affection. In fact, among 289 cases in private practice, 
kept under observation for a longer time, as a rule, hemoptysis occurred 
in 41.8 per cent., but it is to be recollected that even these patients 
were under observation for less than half of their duration. Hemor- 
rhage is more apt to occur in advanced cases, and those who base their 
calculations on early cases in sanatoriums are likely to find low per- 
centages, while when only fatal cases are taken the percentages will 
be too high. 

1 British and Foreign Med. Chir. Review, 1849. 

2 Diseases of the Lungs and Pleura, London, 1891, p. 785. 

8 In Brauer, Schroder, and Blumenfeld's Handbuch d. Tuberkulose, ii, 25 0. 
4 Jour. Am. Med. Assn., 1907, xlix, 1067; 1909, liii, 455. 



202 HEMOPTYSIS 

Initial Hemoptysis. — Of great interest is hemoptysis as an initial 
symptom of phthisis. But statistics on this subject are also at variance, 
because we meet with many patients who have been coughing and 
presented other symptoms of tuberculosis for months, or even years 
and paid little attention to them till a hemorrhage brought them to 
their senses. Here it would not be correct to consider the hemoptysis 
as the first symptom. 

In a study of 1932 cases Reiche 1 found that 9.2 per cent, had more 
or less profuse hemorrhage at the beginning of the disease, and in 
one-fourth of these it was rather copious. He finds that those who 
bleed at the beginning are more apt to bleed during the course of the 
disease than those who do not; the ratio is 57.9 per cent, and 31.7 
per cent. Sorgo found during a period of observation extending over 
ten years that 12.9 per cent, of 5872 patients had initial hemorrhages. 
Kuthy 2 reports that while 54.3 per cent, of his patients had hemoptysis, 
only two-fifths of these (22.3 per cent.) were initial hemorrhages. 
Anders arrives at the conclusion that in about 10 per cent, of cases 
of phthisis, hemoptysis first directed attention to, and is almost invari- 
ably followed by, demonstrable and conclusive evidence of the disease; 
but in not less than 25 per cent, of all cases of chronic pulmonary 
tuberculosis, hemoptysis is among the ushering-in symptoms of the 
active recognizable period of the affection. 

Pathology. — The diagnostic and prognostic significance of hemop- 
tysis can only be appreciated when we have a clear understanding 
of the anatomical changes responsible for the bleeding. There are 
several varieties of pulmonary lesions which may bring about extrava- 
sation of blood from the lung tissues: Local inflammatory or active 
hyperemia; ulceration of a bloodvessel, and aneurysmal dilation of 
bloodvessels are the most important in phthisis. 

The initial hemoptyses are said to be caused merely by localized, 
active inflammatory hyperemia. In other words, they are of the same 
origin as the rusty sputum of pneumonia. But we may well under- 
stand that this bleeding, caused by diapedesis, cannot be profuse — 
only blood-streaked sputum may thus be brought about. This is met 
with in all stages of phthisis and can only be accounted for in this 
manner. On the other hand, blood-streaked sputum does not invari- 
ably mean that it is caused by localized hyperemia and that the lesion 
is not serious, because not all the extravasated blood is brought out 
through the mouth. Quite some of it remains in the lungs and bronchi, 
and is more or less quickly absorbed, as was shown by Nothnagel. 
When the hemorrhage is not profuse we must not conclude that the 
case is mild, or that the lesion is not extensive. 

When the pulmonary lesion proceeds from infiltration to caseation, 
then to softening, and finally to liquefaction, it undoubtedly implicates 
the bloodvessels that pass through it and produces in them the same 

i Ztschr. f. Tuberk., 1902, iii, 223. 

2 Die Prognosenstellung bei der Ltmgentuberkulose, p. 299. 



PATHOLOGY 203 

changes as in the lung tissue. It is therefore strange at first sight that, 
considering the ulcerative processes and the destruction of tissue, 
hemorrhages do not occur more often. But this is explained by the 
strong tendency to the formation of thrombi in the bloodvessels, except- 
ing in very acute cases. In chronic cases there usually occurs a narrow- 
ing, or complete obliteration, of the vessel by the growing tubercles 
which, when finally ulcerating, may leave an erosion through which the 
blood can flow more or less freely until it is occluded by a thrombus. 
Moreover, the increased blood-pressure at the infected and inflamed 
area dilates the softened vessels, and causes small aneurysms, the 
aneurysms of Rasmussen, which have been described elsewhere (see 
p. 149). This is clear when we bear in mind that the bloodvessels 
in the lungs are terminal branches of the pulmonary artery. These 
aneurysms may easily rupture and permit blood to escape. 

Most cases of hemoptysis end in recovery, and the pathological 
changes in the lung at the time of the bleeding can only be surmised, 
but in fatal hemorrhages we often have an opportunity to observe the 
anatomical changes. Here we usually find that the source of the 
bleeding was an exposed vessel, left bare after the surrounding pul- 
monary tissue had softened and was eliminated. The loss of support, 
as well as the pathological changes in the perivascular tissues, and the 
erosions of the tunicse adventitia and media, lead to aneurysmal dilata- 
tions of the inner coat which give way to the pressure exerted on them 
by the circulating blood. 

The rupture of these aneurysms at times strikes down a patient 
who is on the road to recovery when a hemorrhage occurs like a storm 
out of a clear sky. When the cavity into which the aneurysm or the 
lacerated artery opens is small, the extravasated blood usually coagu- 
lates, and the clot obstructs the opening of the bloodvessel, thus stop- 
ping the bleeding. But in large cavities, or when the blood is deficient 
in coagulability, which is not rare, the bleeding keeps on until the 
patient dies of acute anemia. I have seen at autopsy a large cavity 
filled with about a quart of blood which killed a patient during the 
night. After clearing out the clots we found an eroded artery about 
2 mm. in diameter, and passing a probe through it, we found it only 
about 6 cm. from the pulmonary artery. This patient had such a sharp 
hemorrhage that he was unable to call for assistance. 

In more acute cases of phthisis, in which the destruction of lung 
tissue is going on at a rapid pace, the hemorrhages usually come from 
ulcerating erosions of large pulmonary vessels and may prove fatal 
immediately. Here there is no time for narrowing of the bloodvessel, 
thus preparing it that in case of rupture it may be easily repaired by 
occlusion with a thrombus which saves the majority of chronic con- 
sumptives from death due to this cause. In acute pneumonic phthisis 
which very often begins with sharp and profuse hemorrhage, I have 
usually been able to find signs of cavitation when the acute process 
subsided and the disease pursued a chronic or subacute course. This 



1 



204 HEMOPTYSIS 

confirms the view that profuse hemorrhage is not caused by mere active 
inflammatory hyperemia, but by actual erosion of a bloodvessel. 

In fibroid phthisis the sources of hemorrhages are lacerated, dilated 
or varicose bloodvessels which pass through bronchiectatic cavities, 
characteristic of this form of the disease, and also oozing from capillaries 
or arteries which traverse the granulations on the walls of the cavities. 
The bleeding is therefore not profuse, as a rule, but it is recurring in 
many cases. 

Hemoptysis at the Onset of Phthisis. — As the first symptom to draw 
the attention of the patient to his affection, hemoptysis occurs in two 
different types. We meet it in patients who have felt perfectly well 
until the instant the hemorrhage made its appearance without any 
premonitory symptoms. Even close questioning does not elicit any 
symptoms preceding the bleeding. While at work, or engaged in an 
animated conversation, or even waking up from sleep during the night, 
the patient feels a sensation of warmth in the throat, coughs, and expec- 
torates a mouthful of blood; or during a fit of coughing he brings up 
some blood-streaked sputum. A careful examination of the chest and 
skiagraphy may fail to disclose anything conclusive of pulmonary dis- 
ease. The temperature is and remains normal, the appetite is good, 
but for a few hours or days the patient continues to bring up dark clots, 
and when this ceases he is apparently none the worse for his experience. 
Many of these patients subsequently pass through life without ex- 
periencing anything that may lead to the suspicion of tuberculosis. 
This is seen in many who have passed through an attack of abortive 
tuberculosis, details of which are given later on. Some patients give 
a history of such a hemorrhage many years before the onset of active 
phthisis. 

In others the initial hemorrhage continues for several days, and 
when it finally ceases the patient shows symptoms of phthisis — 
cough, expectoration, tachycardia, nightsweats, etc. Physical explora- 
tion of the chest reveals distinct signs of a lesion in one or both apices 
and tubercle bacilli may be found in the sputum. The subsequent 
course of the disease is that of chronic phthisis, though a large propor- 
tion of cases are aborted within a few months, and I have met with 
patients who have had several attacks of hemoptysis at long intervals, 
have shown some indefinite or even conclusive apical signs, and rarely 
tubercle bacilli in the sputum, yet they remained well indefinitely. 

A different clinical type of hemoptysis is seen in patients who main- 
tain that they had felt quite well, but close questioning reveals the 
fact that they have been coughing for months, bringing up mucopuru- 
lent sputum; that the appetite has failed, and that they have lost 
weight and strength. In women we may find that they have missed one 
or more of their periods. They, however, considered these symptoms 
trifling, and continued at their work; or, consulting a physician, they 
were told that it was only a slight "cold." 

The hemorrhage in these cases is apt to be profuse and to last for 



HEMORRHAGES DURING THE ADVANCED STAGES 205 

several days because, while insidious in its arrival, the tuberculous 
process in the lungs has usually progressed quite far; indeed I have 
met with signs of pulmonary excavations in such " initial" hemorrhages. 
In the majority of cases physical exploration of the chest reveals a lesion 
of moderate extent, though on rare occasions we find nothing definite, 
even with the aid of skiagraphy. But the cough, fever, nightsweats, 
expectoration, etc., continue and the diagnosis is made without con- 
clusive physical signs. In most cases tubercle bacilli are found in the 
sputum. It is the slow and prolonged convalescence after the attack 
of hemoptysis that distinguishes these cases from the initial hemor- 
rhages of abortive tuberculosis. 

Hemorrhages during the Advanced Stages—In confirmed chronic 
cases of phthisis we may meet with hemoptysis at any period of the 
disease, though it may be added that it is most frequent in the early, 
and very late stages. The bleeding may be of various degrees, from 
that of sputum tinged with blood, to the expectoration of several 
mouthfuls of pure, bright red blood, to a copious hemorrhage during 
which several pints are brought up within twenty-four hours, and in 
rare cases it has been reported that as much as three quarts of blood 
were brought up. 

The blood is bright red, frothy, usually mixed with sputum. When 
bleeding is very profuse the blood may be "blue," or venous. It is 
evident that in most cases the blood does not coagulate quickly — 
some clots are seen, but the bulk remains fluid; even the addition 
of calcium salts, serum and tissue extracts does not enhance its 
coagulability. E. Magnus iUsleben 1 has added normal blood without 
increasing its power of coagulation. The reasons for this delayed 
coagulability are not clear. 

Many patients have some premonitory warning before the onset of 
hemoptysis, and I have had one who could foretell bleeding twenty- 
four hours in advance. At times there is a rise in temperature, and 
pains in the chest are aggravated, or the cough becomes more annoying. 
But in most patients the onset is sudden and unexpected. The patient 
has a sensation of gurgling or tightness in the chest, followed by a 
fit of cough productive of bright red, frothy blood which has a salty 
taste and partly coagulates in the vessel into which it is deposited, 
forming flattened lumps. When very profuse, which is comparatively 
rare, the patient is overwhelmed and can hardly cough — the blood 
gushes in an almost steady stream through the mouth and at times 
through the nose. 

The general appearance of the average patient is that of shock — 
he is prostrated, often out of proportion to the amount of blood lost; 
his countenance is that of a frightened individual, unnerved, anxious 
and terrified; the face pale, the extremities cold and clammy. The 
temperature, which may have been above normal before the onset of 

i Ztschr. f. klin. Med., 1914, lxxxi, 9. 



206 HEMOPTYSIS 

the bleeding, suddenly sinks, often to a subnormal degree; the pulse 
is rapid, soft and small. 

That these symptoms of collapse are not due wholly to the loss of 
blood is evident from the fact that the family is also panic-stricken, 
and some are in the same state of collapse as the patient, showing the 
profound influence this symptom has on the average person. 

After getting some reassuring encouragement from his physician, 
there is usually observed a reaction in the patient — the pulse improves, 
the face becomes flushed, and the temperature rises to the same degree 
as it was before the onset of the bleeding, or higher. In many cases 
there is soon a relapse, the bleeding is repeated within a few hours or 
the next day, and it may keep on at irregular intervals for a week or 
more. When it finally stops the patient continues to expectorate 
dark blood-clots with his sputum for several days. In some cases the 
bleeding continued for weeks, letting up for a day or two, to reappear; 
rarely until the patient expires from exsangumation, cerebral anemia, 
and cardiac asthenia. 

In cases with large pulmonary cavities the bleeding may be very 
copious. The quantity of blood brought out is not all that has escaped 
from the bleeding vessel. A considerable part is swallowed automatic- 
ally, and some remains in the cavities or the bronchi, and is subse- 
quently absorbed. The outcome of the bleeding depends on the size 
of the cavity and the coagulability of the blood. In rare cases the 
weak and emaciated patient is overwhelmed by the bleeding and is 
unable to expel it from the lungs, expiring in a few minutes, drowned 
or suffocated by his own blood. Other patients make a vain fight 
for hours, or days, but finally succumb to exanguination. But the 
chances of recovery of a bleeding patient with a cavity in the lung 
are, on the whole, not bad. An immediate fatal issue is, after all, 
exceptional; less than 2 per cent, of bleeding consumptives die from hemor- 
rhage directly. The vast majority of hemorrhages are well borne, the 
patient dying, if at all, from other symptoms or complications. 

On the other hand, we meet with patients who have made an excellent 
recovery, but suddenly profuse hemorrhages occur which carry them 
off within a few hours or days. I was once called to attend a patient 
who was discharged from a sanatorium three days previously as an 
arrested case of phthisis. He succumbed to the bleeding. These 
hemorrhages are fortunately rare and are usually due to the rupture 
of an aneurysm in a dried and contracted cavity. They can neither be 
foreseen nor prevented. 

Hemorrhages in Fibroid Phthisis. — In this form of phthisis hemop- 
tysis is very frequent. In most cases it is very slight, only blood- 
tinged sputum being brought up. The patients may feel quite well in 
general, excepting for the dyspnea and the cough to which they have 
adapted themselves. But no sooner does blood make its appearance 
in the sputum than they are alarmed. I have, however, had some 
patients who did not mind the blood-tinged sputum much, knowing 



EXCITING CAUSES OF HEMOPTYSIS 207 

from experience that it is not at all dangerous. Profuse and even 
fatal hemorrhages may, however, occur in fibroid phthisis. 

Hemorrhagic Phthisis. — There is a form of phthisis which is char- 
acterized by frequent and recurrent hemorrhages, the hemorrhagic 
phthisis of the old writers. The bleeding occurs at irregular intervals 
for years without harming the patient very much. In these patieuts 
we may not find any definite physical signs in the chest, no fever, no 
pronounced emaciation, and but little cough. Only the hemoptysis 
and, at times, the bacilli in the sputum reveal the condition. I have 
had under my care at the Montefiore Home a woman in whom neither 
any of the other physicians, nor myself, was quick in making a diag- 
nosis of tuberculosis from the indefinite physical signs and the skia- 
gram of the chest. In fact, we had suspected malingering and employed 
strong measures to make sure that the temperature readings were 
not influenced by manipulations of the thermometer, and that the 
sputum was expectorated by the patient, suspecting that there was 
some deception on the part of the patient, who liked to remain in the 
hospital. Even during the more or less copious attacks of hemorrhage, 
which recurred at frequent, but irregular, intervals and often lasted 
for several weeks, no conclusive physical signs could be elicited in the 
chest. I have another patient who has bled at least twice a year for 
the past fifteen years and feels quite well. Andral mentions a case 
which bled off and on for sixty years and finally succumbed at the age 
of eighty to some disease of the chest. These cases are uncommon 
but we meet them now and then. In some, we find signs of more or 
less extensive pulmonary lesions which remain stationary, or quies- 
cent, in spite of the recurring hemorrhages. The lesion is benign 
notwithstanding the tubercle bacilli which are found in the sputum, 
and at times, though rarely, there may be one hemorrhage which 
proves fatal. It has been stated that in most of these cases the lesion 
is localized in the tracheobronchial glands. 

Exciting Causes of Hemoptysis. — We have seen that while hemop- 
tysis is rather common among consumptives, still many pass through 
the disease until the end, recovery or death, without this accident. 
There appears to be some evidence showing that tall persons are more 
likely to bleed than those of shorter stature, and Wolff states that for 
this reason women show a lesser proportion of bleeders than men. 
Strandgaard 1 suggests that the tall patients are more likely to bleed 
because they have larger hearts and higher blood-pressure, but this 
view has not been confirmed. While hemoptysis has been seen at all 
ages, even in infants, still most of the cases occur between fifteen and 
fifty, probably because at this period most of the cases of phthisis are 
active. 

From Ander's statistics it appears that males are more liable to 
hemoptysis than females, and prior to the twentieth year of age there 

i Ztschr. f. Tuberk., 1908, xii, 209. 



208 HEMOPTYSIS 

is a slight preponderance in favor of the female sex. In Thompson's 1 
collective investigation the women showed greater liability than the 
men. But Anders shows that this increased incidence in the female 
sex is confined principally to the first two decades of life. After the 
thirtieth year the number of males preponderates. Females are also 
less liable to suffer from copious and fatal hemorrhages. My own 
experience coincides with that of Anders, that an immediately fatal 
hemorrhage is relatively rare in women. Initial hemoptysis is also 
less frequent in women than in men. Reiche's statistics show that it 
occurred in 11 per cent, of the latter as against only 5.5. per cent, in 
the former; Sorgo found the ratio as 11 and 13.5 per cent, respectively; 
while Berthold Miiller 2 found it in equal proportion in both sexes. 

Some nineteen hundred years ago Aretseus described the "hemop- 
tysical constitution" as distinguished by brilliant whiteness of the skin, 
bright redness of the cheeks, narrowness of the chest, alar scapulae, 
slenderness of the limbs and trunk, combined with a certain degree of 
adipose and lymphatic stoutness. Laennec said that phthisical subjects 
possessing this bodily configuration are more subject to hemoptysis 
than others. 

Patients with a nervous and excitable temperament are more apt 
to suffer from this complication than the indolent and phlegmatic. 
During some animated conversation, overexertion, singing, running, 
mountain climbing, straining at stool, or as a result of traumatism, 
hemorrhage may be provoked. But we should not overestimate the 
effects of overexertion in the causation of hemoptysis. Streaky sputum 
or mild hemorrhages may be caused by overwork or excitement. But 
copious hemorrhages are due to rupture of an aneurysm of Rasmussen, 
or the erosion of a comparatively large branch of the pulmonary artery 
by a tubercle. Perhaps the fact that the majority of copious and fatal 
hemorrhages occur during the night shows clearly that overexertion 
is not the main factor. We are in tbe dark as to why these hemorrhages 
are more likely to occur during the night. Consumptives who have 
been urged on to eat excessively, becoming plethoric, ruddy, and fat, 
bleed more often than those who eat well, but moderately. Exposure 
to the inclemencies of the weather may excite hemoptysis, probably by 
causing an acute localized pneumonic process at the site of the tuber- 
culous lesion. Coitus may excite it and I have known two cases of 
fatal hemorrhage which occurred soon after intercourse. 

Certain drugs used extensively in phthisiotherapy, as arsenic, 
creosote and its derivatives, the iodides, aspirin, etc., are often instru- 
mental in bringing on hemoptysis. It has been stated that residence 
in high altitudes favors hemoptysis, but it has not been proved; as 
will be shown elsewhere, the prognosis of hemorrhage appears to be 
worse in these regions than at sea level. 

Some authors have found that there are seasonal influences in the 

1 Causes and Results of Pulmonary Hemorrhage, London, 1879. 

2 Ztschr. f. Tuberk., 1910, xiii, 133. 



DIAGNOSTIC SIGNIFICANCE OF HEMOPTYSIS' 209 

production of hemoptysis, saying that the spring and summer months 
give the highest incidence, while Ander's collective investigations show 
that it is most prevalent in the months of December, January, and 
February; August, September, May, and March, in the order named, 
seemed to rank next. The experience at the Phipps Institute coincides 
with those of Anders. Burns 1 says that "barometer changes seem 
to have little effect on the symptomatology. In a few instances hemor- 
rhages have occurred following a fall in the barometer but in insufficient 
number of cases to justify constant relation. It is probably a matter 
of coincidence" only so far as the barometer alone is concerned. There 
is a larger number of patients streaking in March, May and especially 
June than in other months. Hemorrhage occurred more frequently 
in June than in any other month." 

I have observed in my hospital work that hemorrhages at times occur 
in epidemic form, a large number of patients bleed at the same time 
in a ward. This may be explained by some intercurrent infection, ' 
especially influenza, causing pulmonary congestion. But psychic 
influences may also be at work. 

Any of the above-mentioneo 1 factors may be the apparent exciting 
cause, but this is not true of the majority of cases. In my experience, 
a large proportion of hemorrhages, especially copious ones, begin when 
the patients have the least reason to expect them. It is the universal 
experience in sanatoriums that patients who have been kept under 
a rigorous rest cure may bleed. As was already mentioned, more than 
one-half the serious hemorrhages begin during the night, when the 
patient is resting in bed, or sleeping, and suddenly wakes up with a 
cough, followed by a mouthful of blood. In patients with eroded blood- 
vessels or miliary aneurysms in the lungs, bleeding is apt to occur with- 
out any known provocative cause, and usually it cannot be prevented 
by any known means. 

Diagnostic Significance of Hemoptysis. — It has been repeatedly 
stated that all cases of hemoptysis should be considered of tuberculous 
origin and treated accordingly until proved to be due to some other 
cause. But just because the vast majority of hemoptyses are due to 
tuberculosis of the lungs, when the blood is derived from some other 
source, it at times proves a serious source of error. There is left a 
wide margin of error when we attempt to follow this principle of con- 
sidering every case of hemoptysis as tuberculous. Cabot, among 
3444 cases of hemoptysis treated at the Massachusetts General Hos- 
pital, found onlv in 1723, or 50 per cent., was the bleeding due to 
phthisis; Jex-Blake, in 54.6 per cent, of 909 patients; and Strieker 
77.6 per cent, of 900 patients with a history of hemoptysis. Ware, 
among his private patients, observed 386 cases of hemoptysis among 
whom no less than 62 showed no evidence of disease, which would 
explain the occurrence of blood-spitting. Among the patients who 

1 Boston Med. and Surg. Jour., 1914, clxx, 564. 
14 



210 HEMOPTYSIS 

consult me at my office, fully 50 per cent, of those who have hemoptysis 
are not at all phthisical. 

The most perplexing cases that present themselves in physicians' 
offices are patients who claim that several days ago they expectorated 
blood. In many the blood was derived from the nose, throat, gums, 
etc. Examination of these parts may not reveal any irritation, hyper- 
emia or varices, while in the chest there are found some indefinite signs 
of an apical lesion which may be of non-tubercubus origin, thus leading 
to an erroneous diagnosis of tuberculosis. This is especially seen in 
cases of epistaxis in which the blood trickled down the posterior nares, 
exciting cough productive of blood, or blood- streaked sputum. Some 
patients have epistaxis during the night, wake up spitting blood and 
present themselves promptly in the morning for a medical examination 
which does not reveal any definite clues as to the source of the bleeding. 

Streaky Sputum. — Great care must be exercised before diagnosing 
tuberculosis based on a history of blood-streaked sputum. While 
this, when originating in the lungs, may be a precursor of a large and 
profuse hemorrhage, it is, however, a fact that streaky sputum only 
rarely originates in the pulmonary parenchyma; the vast majority 
comes from the nose, throat and especially the bronchi. West 1 says 
that streaky hemoptysis is far more frequent in bronchitis than in 
phthisis. When it occurs in phthisis it is generally due to the same 
cause, viz., the rupture of distended capillaries in the bronchial tubes 
as the result of violent coughing; but when the tubes are the seat of 
tubercular ulceration, bleeding may sometimes take place from the 
ulcerated surface, usually in small amount and streaky, but occasion- 
ally in larger amount. Individuals suffering from chronic rhino- 
pharyngeal inflammation of any sort at times expectorate blood- 
streaked sputum. This occurs largely in the morning; while "clearing 
the throat" some mucus is expectorated showing streaks of blood. 
The patient is frightened, and with a view of convincing himself, 
begins to cough more strongly, finding on inspecting the material that 
it really does contain blood. The force used to dislodge the attached 
secretions may be responsible for the streaks of blood brought out. A 
careful examination of the throat may not show anything suggestive 
of the source of the blood. 

In addition to rhinopharyngeal catarrh there are other conditions of 
the throat which may produce hemoptysis. Among them may be men- 
tioned certain new growths of the larynx, such as vascular fibromas, 
hemorrhagic laryngitis, etc. In several cases under my care these non- 
tuberculous conditions proved to be a source of error. 

In many cases with a history of streaky sputum the diagnosis can 
only be cleared up by careful observation for weeks, after the presence 
or absence of fever, tachycardia, anorexia and physical signs in the 
chest are carefully studied. Very often the blood is derived from con- 

1 Diseases of the Organs of Respiration, London, 1909, ii, 381. 



, DIAGNOSTIC SIGNIFICANCE OF HEMOPTYSIS 211 

gestion in chronic pharyngitis with a spongy mucous membrane, or 
from dilated or varicose bloodvessels in the trachea, or main bronchi, 
common in asthma and chronic bronchitis. Varicosities of the esoph- 
agus are also said to be quite common. These "esophageal piles" 
may cause very copious hemorrhages. Recently Gorel and Gignoux 1 
have described fausses hemojptyses due to varices at the base of the 
tongue which are visible in the laryngeal mirror. The vein may be 
large and dilated and often extends to the fold of the epiglottis, or only 
a number of blue or dark blue specks may be noted, at times confluent, 
greatly resembling a vascular tumor. These are very often causes of 
hemoptysis. They are found mostly in persons between forty and fifty 
years of age, especially those who show other stigmata of arterio- 
sclerosis and other varicosities, as on the legs, or hemorrhoids. 

These false hemoptyses have been described by many English 
physicians. Williams 2 speaks of persons who, without any symptoms 
of lung disease, bring up quantities of blood and recover without 
permanent cough. He says that they were generally middle-aged and 
often had the arcus senilis. Recovery is the rule. Sir Andrew Clark 3 
also describes " arthritic hemoptysis" occurring in elderly persons free 
from ordinary disease of the heart and lungs; a form of hemoptysis 
arising out of minute structural alterations in the terminal bloodvessels 
of the lung. These vascular changes occur in persons of the arthritic 
diathesis, resemble the vascular alterations found in osteo-arthritic 
articulations, and are themselves of an arthritic nature. More recently 
F. de Havilland Hall 4 attributed these hemorrhages to high vascular 
tension. Even though it occurs in a patient who has had phthisis, this 
form of hemoptysis is not necessarily due to a recrudescence of the 
disease, but may be the result of high tension with degenerate 
vessels. 

At times persons suffering from pulmonary emphysema expectorate 
blood-streaked sputum, especially after paroxysmal cough. In rare 
instances I have observed emphysematous subjects expectorating pure 
blood — as much as an ounce or two. While in such cases we always 
suspect that we are dealing with the emphysematous form of fibroid 
phthisis (see p. 378), yet I have seen many cases in which subsequent 
observation, for a long period of time, has shown conclusively that the 
hemoptysis was not of tuberculous origin. 

Hemoptysis during Acute Respiratory Diseases. — We have already 
mentioned that acute rhinitis, pharyngitis, tonsillitis, etc., may be 
accompanied by the expectoration of blood. In fact, when a patient 
complains of hemoptysis and shows signs and symptoms of an acute 
affection of the upper respiratory tract the chances are greatly in favor 
of the blood being derived from the rhinopharynx and not from the 

1 Lyon Medical, 1911, xliii, 1913. 

2 Pulmonary Consumption, London, 1887, p. 135. 

3 Tr. Med. Soc. of London, 1889, xii, 9; Lancet, 1889, ii, 840. 
"Lancet, 1915, ii, 329. 



212 HEMOPTYSIS 

lungs. Moreover, tuberculosis never begins with a acute coryza, 
pharyngitis, or tonsillitis. 

In lobar pneumonia the rusty sputum is characteristic. But in many 
cases the expectoration of pure, bright red blood is observed. In bron- 
chopneumonia, hemoptysis is even more frequent, and during the recent 
epidemic of influenza the vast majority of patients in whom pneumonia 
complicated the process had more or less profuse hemorrhages. The 
differentiation is made by the history of the case, its epidemic occur- 
rence, the symptomatology which is characteristic of influenza, and 
the location of the pulmonary lesions. 

Hemoptysis in Pleurisy. — In many cases of pleurisy with effusion the 
onset is with a more or less copious pulmonary hemorrhage. I have met 
many cases in which after the bleeding ceased a physical examination 
revealed an effusion into the pleura. In some phthisis developed sub- 
sequently, but others remained well for an indefinite time after the 
effusion was absorbed. I have also noted that this is more likely to 
occur in cases of interlobar pleurisy, first described by Dieulafoy. 
There may be blood-streaked sputum, and at times abundant hemop- 
tysis, which may recur at variable intervals. After the interlobar 
effusion has been absorbed, or an abscess remains after an interlobar 
empyema, recurrent attacks of hemoptysis may occur. The differen- 
tiation of these cases from tuberculosis is discussed elsewhe/e in this 
book. 

Hemoptysis in Heart Disease. — Blood-spitting in heart disease is 
often treated as of tuberculous origin with disastrous results. In- 
asmuch as we very often meet with cardiacs who are emaciated, cough, 
and have occasionally mild pyrexia, the diagnosis of tuberculosis is 
at times made erroneously. It is in fact usually supported by some 
physical signs in the chest, because cardiacs may show defective 
resonance, alteration in breath-sounds, and even rales over an apex, 
or other parts of the chest as a result of infarction, peripheral throm- 
bosis, or brown induration. I have seen cases of organic heart disease 
treated in tuberculosis clinics and day camps in New York City for 
months. In infarction the expectorated blood may be bright red, 
but in mitral disease small, solid, purple or black lumps which sink in 
water are usually brought up. They are derived from ruptured capil- 
laries in the walls of air cells where they remain for some time before 
they are expectorated. The experienced eye can generally distinguish 
them. 

According to Frederick W. Price, 1 mitral stenosis is probably the 
next most frequent cause of hemoptysis to pulmonary tuberculosis 
and a common source of error. Among 3444 cases of hemoptysis in 
the Massachusetts General Hospital, R. Cabot 2 found that in 1177, 
or over 34 per cent., the bleeding was due to mitral disease. Perhaps 
the heart is not examined at all, or if it be examined it is by no means 

1 British Med. Jour., 1912, i, 287. 

2 Differential Diagnosis, 1914, ii, 433. 



HEMORRHAGES FROM THE ESOPHAGUS 213 

rare for the characteristic murmur to be absent. Furthermore, because 
there are frequently apical signs, as has already been indicated, phthisis 
is often diagnosed. In several cases I was nearly trapped by this 
similarity of mitral disease to phthisis, but noting some irregularity in 
the heart-beat, I investigated further and diagnosed mitral stenosis. 
It must always be remembered that while active phthisis is not alto- 
gether excluded with heart disease, yet it is extremely rare, especially 
in mitral stenosis. 

In aneurysm of the aorta the end often comes through a rupture of the 
sac and fatal hemoptysis occurs. But in many cases streaky sputum 
is seen for weeks or even for months before the fatal hemorrhage 
finally kills. I have seen several cases in which pressure exerted by 
the aneurysm on the lung, or on a bronchus, produced signs simulating 
an apical lesion. 

In pulmonary infarction hemorrhage is the rule. Mistakes of con- 
founding these cases with tuberculosis may be avoided by a careful 
consideration of the history of the patient, an examination of the 
peripheral veins, the heart, etc. Still, many of these patients are often 
treated for tuberculosis because of the hemorrhage (see p. 487). 

Hemoptysis in Bronchiectasis and Syphilis of the Lungs. — In bron- 
chiectasis bleeding is not uncommon, and I have seen copious hemor- 
rhages due to this cause. The blood is derived either from dilated 
and congested bloodvessels in the proliferated mucous membrane, 
or from inflammatory changes in the mucosa, or from small eroded 
aneurysms in the walls of bronchiectatic cavities, similar to those 
found in tuberculous excavations. As a rule, it is encountered in older 
persons. During the hemorrhage the diagnosis may be difficult, 
though a careful history clears up the case. In syphilis of the lungs, 
hemoptysis of various degrees has been encountered. 

Hemoptysis often occurs in cases of cancer of the lung, and is at times 
a source of error in diagnosis. In the early stages of cancer of the lung 
the symptoms may simulate those of tuberculosis very closely. The 
bleeding, if it does occur, is usually very obstinate; the patient keeps on 
expectorating dark clots of blood. Pure, bright blood is rare at this 
stage. The differential diagnosis is discussed in its proper place (see 
p. 483). In advanced cancer of the lung there may occur copious 
pulmonary hemorrhages. In old persons we may not be able to find 
sufficient signs to clear up the local lesion, and only a radiographic 
plate may show the real cause of the bleeding. 

Other pulmonary diseases which may cause hemoptysis are fibrinous 
bronchitis, some cases of gangrene of the lung, echinococcus, and 
actinomycosis of the lungs. The differential diagnosis is discussed in 
Chapter XXVIII. 

Hemorrhages from the Esophagus. — Varicosities of the esophagus, 
"esophageal piles," have already been mentioned as liable to cause 
hemorrhages which closely simulate pulmonary hemoptysis. In one 
case under my observation the bleeding was copious, almost threaten- 



214 HEMOPTYSIS 

ing, and a diagnosis could not be made for some time. There have been 
reported cases in which the mucous membrane of the gullet was covered 
by enlarged, dilated, and tortuous veins. It is mostly found in persons 
suffering from cirrhosis of the liver. But it may occur in those who have 
no hepatic trouble. Patients suffering from cancer of the esophagus 
also may bring up blood with their expectoration; in the advanced 
stages of the disease the bleeding may be copious. The neoplasm may 
extend to and perforate a bronchus, and the blood may thus be brought 
out through the trachea and larynx. The diagnosis should offer no 
difficulties to those who carefully examine their patients. 

Menstrual Hemoptysis. — Phthisical women, if they are to have 
hemoptysis at all, are more apt to have it during the menstrual period. 
It has been observed that during menstruation there is usually an 
increased blood-pressure and congestion of the laryngeal mucous 
membrane, and some state that active periodical hyperemia of the 
lungs occurs at that time and this would favor extravasation of blood, 
especially in the affected area. According to Macht 1 these periodical 
hemorrhages, which may be very slight or profuse, may persist after 
the patient has improved in health and the tuberculous process becomes 
arrested. Periodic hemorrhages in consumptives at the time of 
menstruation may take place from other organs than the lungs. Thus, 
"Wilson and Newman have reported such hemorrhages from the trachea 
and upper respiratory passages. Macht also reports a rather interesting 
case of a woman with pulmonary tuberculosis with intestinal compli- 
cations — ulcer in the bowels — who regularly had severe hemorrhages 
from her intestines at her periods. 

Vicarious menstruation, which is very rare, appears to be due in 
most cases to tuberculosis. But in evaluating vicarious menstruation 
it must be borne in mind that amenorrhea is very frequent in phthisis 
and in this disease hemoptysis is frequent; it is therefore not surprising 
that hemoptysis should occasionally occur while the menstrual flow 
has been delayed or suppressed. 

Hemoptysis is apt to occur in pregnant tuberculous women periodi- 
cally almost to an extent as to suggest that it is vicarious in character. 
On the other hand, non-tuberculous pregnant women have hemoptysis 
at times, especially if they cough severely for any reason. Many cases 
of this sort have come under my observation. After childbirth they 
usually cease bleeding if they are not tuberculous. The diagnosis in 
these cases is very difficult at times because incipient phthisis often 
improves during pregnancy and is thus liable to lead to a false sense of 
security. A careful examination of the chest and several microscopical 
examinations of the sputum will, however, clear up the case in most 
instances. 

Several authors have also reported hemoptysis in women during 
lactation; soon after the infant is weaned, they stop expectorating 
blood. The causes of these hemoptyses are obscure. 

1 Am. Jour. Med. Sc, 1910, cxl, 835. 



HEMOPTYSIS OF NERVOUS ORIGIN 215 

Hemoptysis of Nervous Origin. — In hysterical individuals, especially 
women, we at times observe symptoms of incipient phthisis, including 
hemoptysis, but repeated physical examinations do not disclose any 
pathological changes in the lungs. Physicians of former generations 
have therefore spoken of "hysterical hemoptysis." In most of these 
cases we find that the blood is derived from the gums, or from the 
throat, brought out by violent cough. In their efforts to excite sym- 
pathy they are even apt to produce bleeding mechanically by injuring 
the buccal mucous membrane. When with this there is also cough, 
dyspnea, pain in the chest, and even fever, symptoms commonly found 
in hysterical subjects, the diagnosis is at times very difficult. How- 
ever, in addition to the absence of signs of a lung lesion, there are found 
positive stigmata of hysteria. On the other hand, the fact must not 
be lost sight of that hysterical individuals may become tuberculous, and 
that tuberculous individuals are often manifesting symptoms of 
hysteria. Indeed, some patients who have had one or more attacks 
of hemoptysis become obsessed with the fear for blood and consider 
themselves the most unfortunate among tuberculous patients. When 
told by the physician that their disease is progressing rather favorably, 
they often retort, "Why, doctor, I am a hemorrhage case." This is 
mostly seen in patients who have spent some time in sanatoriums and 
have either bled themselves, or observed copious, perhaps fatal hemor- 
rhages in other patients. They constantly watch their expectoration 
for blood and may, during a fit of cough during the night, rise, light up 
the room and carefully inspect the sputum brought out with a view of 
finding a speck of blood. This fear for bleeding, which one author has 
called hemophobia, may dominate the entire clinical picture, and it is 
at times difficult to manage this class of patients. 

In certain diseases of the cerebrospinal, as well as the peripheral 
nervous system, hemoptysis may occur. Thus, in some cases of loco- 
motor ataxia, cerebral hemorrhage, etc., hemoptysis is at times ob- 
served, though a careful examination of the chest fails to reveal signs of 
a pulmonary lesion. In some cases of epilepsy also it has been observed 
that the patients expectorate blood after a paroxysm. In these cases 
the blood may be derived from the tongue which was injured by the 
teeth. It has, however, been shown that disturbances in the central 
nervous system may result in hemoptysis. Experiments by Brown- 
Sequard demonstrated that after injuries to the pons Varolii there were 
extravasations of blood into the lung tissue. Francois-Frank found 
that strong irritations of the peripheral nerves may result in bleeding 
from the lungs. Lichtheim, Claude-Bernard, Longet, and other 
physiologists have confirmed these experimental findings. 

It must, however, not be rashly concluded that tabetics who expec- 
torate blood are not tuberculous. In most cases that came under my 
observation tuberculous lesions were localized, or positive sputum 
was obtained. In rare cases hemoptysis in tabetics was found to be 
distinctly non-tuberculous in character. 



216 HEMOPTYSIS 

Hemoptysis of Unknown Origin. — We have already mentioned that 
every physician of experience has met with cases of hemoptysis showing 
no symptoms or signs of any disease to account for the bleeding. Very 
frequently we meet with patients in whom the most painstaking 
examination and clinical observation extending over a long period of 
time reveal no cause for the pulmonary hemorrhage. They remain 
healthy indefinitely. In some the hemorrhages are recurring at irreg- 
ular intervals, and at times the amount of blood brought out may be 
considerable. The patient after losing considerable blood remains 
anemic for some time, but soon recuperates, and feels well indefinitely. 
Various suggestions may be made as to the origin of the bleeding, but 
none can be proved to the satisfaction of those who are competent to 
pass an opinion. Those who consider these pulmonary hemorrhages as 
of the same diagnostic significance as epistaxis are as safe in their 
assertions as those who are more explicit and careful in their diag- 
nostic utterances. 

I have met with several of this type of cases treated as tuberculous, 
kept in sanatoriums, or banished to distant climes. But they never 
developed symptoms of active pulmonary phthisis. Emanuel Libman 
and Reuben Ottenberg speak of hereditary hemoptysis. They have 
observed a case in which for four generations more or less copious 
hemorrhages from the lungs occurred at irregular intervals, and in no 
instance has phthisis developed. Similarly epistaxis is occasionally 
seen to run in families. With hemoptysis, however, there is always 
danger that the patient will be pronounced affected with hereditary 
tuberculosis and treated as such, though in fact it is of no more sig- 
nificance than a nose bleeding. 

Some of these hemoptyses of unknown origin may be due to abortive 
tuberculosis (see p. 385). In others it is due to bronchiectasis which is 
not easily diagnosticated. In one case under my observation for eight 
years tuberculosis was diagnosticated and institutional treatment 
instituted; then other conditions were accused, but finally we made up 
our minds that it is due to multiple bronchiectatic cavities. The 
bleeding in this case occurs at irregular intervals, is nearly always 
copious and even threatening, the patient remaining exsanguinated, 
but soon recuperates. It seems that phlebotomy prevents the hemor- 
rhage in this patient, or at least mitigates its severity. 

Localization of the Source of the Hemorrhage. — Heretofore the deter- 
mination of the side of the chest in which the bleeding takes place 
was merely of academic interest because it made very little difference 
on which side the ice-bag, which has been traditionally used in the 
treatment of this symptom, was applied. But recently, since we found 
that an artificial pneumothorax may stop a copious hemorrhage after 
everything else has failed, it is of practical importance to localize the 
bleeding-point. 

In cases which have been under observation for some time, and it 
is known that the lesion is unilateral, the problem may be simple, 



DIFFERENTIAL DIAGNOSIS 217 

inasmuch as profuse bleeding implies an old cavitary lesion. But in 
bilateral cases it is difficult, often impossible, to determine positively 
which lung is bleeding. Percussion must not be done for fear of in- 
creasing the bleeding and auscultation may be of service in showing 
a limited area of moist, consonating rales, and perhaps amphoric 
breath-sounds. But it is a noteworthy fact, which must never be lost 
sight of, that during profuse hemorrhages the blood may be aspirated 
into the non-bleeding lung and produce all sorts of rales. It is there- 
fore, at times, impossible to decide positively which lung is bleeding. 

In rare cases we hear murmurs, synchronous with the heart-beat, 
over the site of excavations. Gerhardt found that these murmurs 
originate in arteries which traverse the walls of cavities and he verified 
his observations at the autopsy table. In several cases this phe- 
nomenon was observed by me, the murmur was audible below the 
clavicle, and over the same area were most of the classical signs of 
pulmonary excavation. These patients are apt to bleed copiously, 
and they often succumb to a sharp hemorrhage. Here we know that 
the source of the bleeding is the branch of the pulmonary artery which 
traverses the cavity, and operative treatment (an artificial pneumo- 
thorax) may be attempted when a hemorrhage cannot be controlled 
otherwise. But these cases are rare and in the average case we cannot 
say with any degree of certainty that the bleeding vessel is located in 
a superficially recognized excavation, and not in another one, either 
located deeper, or altogether in the other half of the chest. I have 
repeatedly seen cases in which after a copious hemorrhage the more 
affected side remained unaltered, while in the unaffected lung signs of 
a new lesion appeared. 

According to Strieker, 1 the bleeding comes from an eroded vessel 
when it occurs suddenly during the course of acute and progressive 
phthisis, while in chronic cavitary phthisis it is usually derived from 
an aneurysmal dilatation of a vessel. Repeated hemorrhages accom- 
panied by fever point to progressive decay of the affected area in the 
lung. Hemoptysis in the advanced stages of phthisis is derived from 
eroded arteries, and for this reason the prognosis is less favorable 
than in hemoptysis in incipient cases or in initial hemorrhages, which 
are, as a rule, of venous origin. 

Differential Diagnosis. — In cases of initial hemoptysis it is impera- 
tive to ascertain whether the blood is derived from a tuberculous 
lesion or is due to some other cause. It must never be lost sight of that 
hemoptysis may be a symptom of every disease of the upper and loiver 
respiratory tracts, tuberculous as well as others. Careful examination of 
the nose and throat may reveal that it is altogether due to congestion or 
varicosity of the mucous membranes of the upper respiratory tract, as 
has already been mentioned. When the sanguineous fluid expectorated 
is uniformly bright red and watery, it is, in all probability, derived from 

1 Nothnagel's Handbuch d. spez. Pathol., xiv, 7. 



218 HEMOPTYSIS 

the mouth. In case no symptoms or signs of a pulmonary lesion are 
discovered, and the bleeding cannot be ascribed to a non-tuberculous 
condition, the heart is normal, and there is no history of an injury, the 
patient is to be placed under prolonged observation before deciding that 
he is not tuberculous. But it must always be borne in mind that mere 
streaks in the sputum may be due to many causes other than tuber- 
culosis of the lungs, and a diagnosis of phthisis should not be made 
because of their presence alone. 

In copious hemorrhage, when it is not feasible to examine the 
patient's chest carefully, it is often difficult to decide whether the 
bleeding is due to a tuberculous lesion, a bronchiectatic cavity, pul- 
monary syphilis or, in rare cases, whether it is not altogether hema- 
temesis. The last-mentioned condition may simulate hemoptysis 
because the patient may have aspirated the blood into the respiratory 
passages and then expectorated it; while in hemoptysis the blood may 
be swallowed and then vomited. It may then greatly simulate blood 
derived from the stomach, viz., black or chocolate-colored, thick 
lumps or clots, mixed with the contents of the stomach, and the stools 
may subsequently show evidences of blood. I have met with cases 
in which the diagnosis could not be made immediately, and I have 
seen several tuberculous patients in whom ulcer of the stomach 
was diagnosed and they, were operated upon. We may, however, 
be guided by the following points: In hemoptysis the blood is, as 
a rule, coughed up, bright red, frothy and mixed with sputum. It 
is also alkaline and does not clot. But many patients swallow the 
blood and then vomit it out; it is then acid in reaction. Ausculta- 
tion may reveal rales in some part of the chest, and a careful history 
will show that the patient has been coughing, expectorating, etc., 
for a long time, while in cases of hematemesis the history points to 
disturbances in the gastric functions, and physical signs may be dis- 
covered in the abdomen. In hemoptysis ice invariably observe that after 
the cessation of active bleeding the patient keeps on coughing and expec- 
torating clotted blood for several days, which is never observed in hema- 
temesis. But when the hemorrhage from either source is brisk and 
copious, and there is no history, the points just enumerated are often 
of little or no value, because the blood is bright red, alkaline, and not 
mixed with either sputum or gastric contents. However, such profuse 
hemorrhages are only seen in advanced consumptives and there are 
always to be noted the stigmata of tuberculosis. 

In cases in which the diagnosis has not been previously established, 
bleeding from the deeper respiratory passages may, on rare occasions, 
be difficult of differentiation as to whether it is derived from a tuber- 
culous lesion or from a bronchiectatic cavity. I have been guided by the 
pulse and temperature of the patient — when these are normal, and the 
general condition of the patient is good, the chances are that there is 
a bronchiectatic cavity, especially in persons over forty-five years of 
age. When physical examination shows that the lesion is localized in 



PROGNOSIS IN INITIAL TUBERCULOUS HEMOPTYSIS 219 

a lower lobe, while the apices are free from pathological changes, the 
disease is almost invariably non-tuberculous bronchietasis, pulmonary 
abscess, gangrene, etc. In older persons with arteriosclerosis the so- 
called "arthritic diathesis" is to be thought of. Usually a careful his- 
tory clears up the diagnosis, while in rare borderline cases we should 
reserve our opinion until the hemorrhage ceases and a careful exami- 
nation of the patient is feasible. 

In addition to tuberculosis the following conditions are liable to 
cause pulmonary hemorrhage : Cardiac disease, aneurysm of the aorta, 
hemophilia, bronchiectasis, syphilis, abscess, and gangrene of the lung, 
certain acute specific fevers, pneumonia, epidemic influenza, suppura- 
tive processes in the mediastinum, foreign bodies in the bronchi, 
injuries to the chest, paroxysms of pertussis, echinococcus, cancer, 
actinomycosis, aspergillosis, hydatid, broncho-pulmonary spiroche- 
tosis, distoma pulmonale ivestermani, and pneumokoniosis. 

Prognostic Significance of Hemoptysis. — Patients, almost without 
exception, overestimate the significance of hemoptysis and are more 
terrified at the appearance of a speck of blood in their sputum than 
by any other symptom or complication of phthisis, excepting perhaps 
spontaneous pneumothorax. It is for this reason that initial hemop- 
tysis has been described by some authors as a salutary phenomenon, 
because it draws the attention of the patient to the condition of his 
lungs which he may have otherwise neglected. In fact, I have known 
cases in which hemoptysis was actually life-saving for just this reason 
in patients who had coughed for months, and presented other symp- 
toms of phthisis, all of which they considered a trifling affair, when, 
like the climax of a slowly developing drama, hemoptysis made its 
appearance, opening their eyes, or even those of their physicians, so 
that proper treatment was instituted. 

A hemorrhage may prove fatal immediately or within a few days 
of its appearance ; or, if the patient survives it, it may have an influ- 
ence on the course of the disease. 

Prognosis in Initial Tuberculous Hemoptysis. — We have already 
mentioned that many cases of pulmonary hemorrhage, even when 
due to tuberculous lesions, are not necessarily followed by symptoms 
of phthisis. Every physician has among his clientele patients who 
have coughed out more or less blood years ago and have never suffered 
from disease of the lungs. "Outspoken tuberculosis does not neces- 
sarily follow hemoptysis," says Frederick T. Lord, 1 "which may occur in 
patients with apparent good health and sound lungs. In 1768, Goethe, 
at the age of nineteen years, and then a student at Leipzig, had an 
attack as follows : 'One night I waked with a severe hemoptysis and had 
enough strength and presence of mind to wake my room-mate . .• . 
for several days I wavered between life and death.' For some months 
he thought he had pulmonary tuberculosis and must die young. At 

1 Diseases of the Bronchi, Lungs, and Pleura, Philadelphia, 1915, p. 360, 



220 



HEMOPTYSIS 



the age of eighty-two years he had hemoptysis again and died at 
the age of eighty-three years. His long and active life may serve as 
a comforting example to those who need encouragement. At the age 
of twenty-three or twenty-four years, Rousseau expectorated blood 
and gave up his work as a teacher of singing. He died at the age of 
sixty-six." A fatal issue in initial hemoptysis is extremely rare. I 
have never seen such a case. 

Proportion of Deaths due to Pulmonary Hemorrhages. — When profuse, 
the patient may be exsanguinated and succumb to cerebral anemia, 
or the blood may overflow the bronchial tree and suffocate him, 
especially when it occurs suddenly while the patient is asleep. While 
this outcome is seen now and then, it is a very rare occurrence. Louis 
had but 3 fatal cases in 300 consumptives; Williams 4 out of 198 
fatal cases; W T ilson Fox 4 out of 101; Moeller saw only 1 fatal hemop- 
tysis during fifteen years' experience with consumptives; Wolff 
reports a lethal outcome three times among 1200 tuberculous patients 
(0.25 per cent.); Winsch 1 among 200 (0.5 per cent.); Thue, 13 times 
among 975 patients (1.6 per cent.); Sorgo 14 deaths among 5800 
consumptives (2.4 per cent.) and among 2.16 per cent, of his patients 
subject to hemoptysis. McCarthy reports that at the Boston Con- 
sumption Hospital 400 deaths occurred during a period of two years, 
only 7 of which were due to hemorrhage. Lord reports that death as 
an immediate result of bleeding occurred in only 1 of 76 patients with 
hemoptysis at the Channing Home, and 2 of 142 at the Massachusetts 
General Hospital. Death as a consequence of extension of pulmonary 
infection for which the hemorrhage was responsible, occurred in 1 case 
at the Channing Home, and 6 other cases at the Massachusetts General 
Hospital. 

Williams reports that in 1000 cases, including 63 fatal ones, where 
the patients had hemoptyses of one ounce and upward on one or more 
occasions, the average duration was seven years and six months; an 
average differing only by a few months from that of the total deaths. 
In 200 living cases of similarly extensive hemoptysis, the average was 
eight years and three months — about the same as that of the living 
cases generally. " It is only in the far-advanced stages that it is likely 
to curtail the duration of the disease. In early cases hemoptysis is 
comparatively unimportant," concludes Williams. When ive say that 
hardly one out of a thousand deaths due to tuberculosis is caused by hem- 
orrhage, we are as near the true figure as possible. 

Influence of Hemoptysis on the Course of Phthisis. — The influence of 
hemorrhage on. the course of the disease is misunderstood by the 
average patient and often overestimated by the physician. It may be 
said that so long as it does not prove fatal immediately, and this is 
rare, as we have just shown, it has no effect on the patient nor on the 
disease. Many older writers have stated that it often has a rather 
salutary effect, and not altogether without reason, as is proved by the 
course of many cases subsequent to hemorrhages. Lebert, Flint, 



INFLUENCE OF HEMOPTYSIS ON COURSE OF PHTHISIS 221 

Wilson Fox, and others state that hemorrhages may produce a sense 
of relief, and cough and expectoration previously existing may tem- 
porarily disappear. Williams says: "To many patients its occurrence 
seems beneficial rather than otherwise, for the congestion is thus 
relieved and the system not materially weakened by the loss of blood." 
/ have seen many cases in whom the disease took a turn for the better, 
soon after a more or less profuse hemorrhage, and others in which the 
cough, anorexia, pains in the chest, etc., disappeared after this accident. 
We know that slight abstraction of blood is often beneficial inasmuch 
as it stimulates the blood-forming organs to produce more blood cells. 

The fear, formerly entertained, that the blood, spreading all over 
the bronchial tree, is apt to inoculate new areas and produce new lesions 
in hitherto unaffected parts of the lung is now known to be without 
sound foundation, because reinfection is difficult or even impossible 
in the vast majority of cases. To be sure, we find that the bronchi 
contain blood while auscultating a patient during, or immediately 
after, a hemorrhage, but this is usually transitory, disappearing by 
absorption or expectoration within a few days after the bleeding 
ceases, and the original pulmonary lesion, if not progressive, remains 
the same as it was before, pursuing the same course as if no such 
accident had occurred. Cases in which after a hemorrhage a quiescent 
lesion begins to pursue an acute or subacute course and tuberculous 
bronchopneumonia is found at the autopsy are, in all probability, 
due to a sudden reduction in the powers of resistance, about the causes 
of which we know nothing at present. They do occur now and then, 
but when taken in connection with the large number of hemoptyses 
in which this sequel does not occur, they are comparatively rare. 

The fear for bronchopneumonia as a sequel to pulmonary hemor- 
rhage, entertained by many physicians, is not founded on fact. In 
afebrile patients, soon after the hemorrhage ceases, the temperature 
may be elevated for a few days, but within a week or so, after the 
effused blood is absorbed, the temperature comes down to the level at 
which it was before this accident. Hemorrhages occurring in febrile 
patients, at times, have the effect that after the cessation of the bleed- 
ing the patient is afebrile, as I have seen in many cases. On the other 
hand, many patients running high fever, when attacked by copious 
hemorrhage, continue with pyrexia after the hemorrhage ceases, and 
finally succumb to the active tuberculous process. How rarely broncho- 
pneumonia follows pulmonary hemorrhage can be seen from figures 
published by C. G. Reinhardt Goodwin: 1 Among 1000 odd cases 
admitted to the sanatorium under his care in the last ten years only 
one case of this kind has been recorded. 

More than sixteen hundred years ago Galen stated that the prognosis 
of pulmonary hemorrhage depends on the fever which is apt to accom- 
pany it — afebrile cases recover, while in febrile cases the prognosis 

1 Practitioner, 1917, xcix, 288, 



222 HEMOPTYSIS 

is gloomy. More extended experience in recent years has confirmed 
the opinion of this ancient and empirical clinician. 

In hemoptysis the immediate, and especially the ultimate, prognosis 
depends less on the bleeding, its abundance or even repetition, than on the 
extent of the pulmonary lesion and the symptoms ichich accompany or 
dominate the clinical picture, the subsequent course of the original disease — 
phthisis — and the complications ivhich may arise. When we find during 
a hemorrhage that a patient has a good, full pulse, less than 100 in 
frequency, and no fever or dyspnea, the immediate prognosis is good. 
If there are several repetitions of the hemorrhage during the subse- 
quent few days, the prognosis is, as a rule, favorable so long as the pulse 
is good and there is no fever. Even fever is of no grave significance if it 
lasts but a couple of days. It is then due to absorption of the blood 
remaining in the bronchi. It is only when the fever is high and per- 
sistent for several days that it assumes serious import. 

In case the pulse becomes small, soft, compressible, and rapid, we 
may be sure that the bleeding continues even if we do no* see it brought 
up in large quantities through the mouth, for we may have internal 
hemorrhage in phthisis, the blood being retained in a large cavity, 
while the feeble patient is unable to force it out by cough. This is 
especially apt to occur after laige doses of morphine have been adminis- 
tered or in severely emaciated persons. 

In cases which had been active before the onset of the bleeding, 
having had fever, tachycardia, emaciation, etc., the prognosis after 
cessation of the bleeding is usually the same as it would have been had 
there been no such complication. The temperature usually drops 
during a brisk hemorrhage, but it rises again and the course of the 
disease continues unabated. But if the temperature has been normal, 
or only slightly above, and the pulse is less than 100, full and bounding, 
the patient has a good appetite, and sedative drugs are judiciously, 
if at all, administered, the immediate as well as the ultimate outlook 
is indeed good. 

In most cases the findings on physical exploration of the chest 
after moderate hemoptysis remain the same as they were before that 
event, although on auscultation we usually hear moist, consonating 
rales which may not have been there before the onset of bleeding. 
These rales may persist for several weeks. In some cases we find that 
the area of dulness over the upper lobe extends because of caseous or 
necrotic changes engendered during the hemorrhage. This dulness 
may disappear after the clots have been absorbed, or after the resolu- 
tion of the pneumonic areas. More frequently it is in time supplanted 
by tympany due to excavation. 



CHAPTER XI. 

SYMPTOMS CAUSED BY DISTURBANCES IN THE GASTRO- 
INTESTINAL TRACT— THE SKIN— THE JOINTS. 

GASTRO-INTESTINAL SYMPTOMS. 

Frequency. — Some authors have stated that phthisis develops mostly 
in individuals who have been naturally bad eaters; others have main- 
tained that those suffering from gastric derangement are most likely 
to fall prey to the disease, and Grancher says that " all consumptives 
have been, are, or will become, dyspeptics." In practice we meet 
with many patients who have been treated for gastritis for a long 
time until the true nature of their disturbance became evident. The 
diagnostic, and especially the prognostic, significance of anorexia or 
gastritis in a disease which depends in its origin and outlook on proper 
nutrition, cannot be overestimated. 

As far back as 1826 Wilson Philip 1 drew attention to the fact that 
many cases of phthisis are preceded for some time by severe indiges- 
tion. In his excellent monograph on the "Dyspepsia of Phthisis," 
W. Soltau Fenwick 2 quotes Todd, Sir James Clark, Budd, Bennett, 
Ancell, and other writers of the first half of the nineteenth century, 
to the effect that dyspepsia is a very frequent forerunner of phthisis. 
In those days some authors even spoke of "gastric phthisis," and 
" pretuberculous dyspepsia" is even now mentioned by many writers. 
There is no doubt that incipient phthisis, as we know it at present, 
was in those days not recognized, and this has been responsible for the 
notion that phthisis is often preceded by dyspepsia. 

Recent investigations, however, do not confirm that gastrointes- 
tinal disturbances are per se predisposing factors in the evolution of 
phthisis, though Fenwick says that, for his own part, he is quite con- 
vinced that there does exist a variety of dyspepsia which is peculiarly 
apt to be followed by pulmonary tuberculosis. 

As an early symptom of phthisis, dyspepsia is quite frequent. Hutch- 
inson 3 found it in 92 per cent, of his cases, and in 55 per cent, it was 
quite severe; Levison, 4 in 74.6 per cent.; Mohler and Funk, 5 in 64.6 
per cent, of 1000 consecutive cases. Samuel Fenwick, Dobell, Pollock, 
and others have found it in nearly similar proportions. W. Soltau 

1 Treatise on Indigestion, London, 1826, p. 323. 

2 Dyspepsia of Phthisis, London, 1894. 

3 Medical Times, 1855, i, 583. 

\Ohio State Med. Jour., May, 1905, i, 204, 
s Amer. Jour. Med. Sc, 1916, clii, 355, 



224 DISTURBANCES IN G ASTRO-INTESTINAL TRACT 

Fenwick states that "dyspeptic phenomena of sufficient severity to 
attract the attention of the patient are encountered in about 70 per 
cent, of all cases of early phthisis, but that the early development 
of the disorder in any individual case depends to a great extent upon 
the sex of the patient, the type of the tubercular disease, and the 
previous condition of the digestive organs." He found that it is more 
apt to occur in females than in males, and, in general, in that variety 
of phthisis which commences insidiously and progresses slowly. 

More recent investigations have only partly confirmed the findings 
of the above-mentioned clinicians, and there are writers who con- 
sider anorexia, though not a result of gastritis, a constant symptom 
of incipient phthisis, like fever, cough, nightsweats, emaciation, etc. 
An analysis of 3007 cases in the Phipps Institute 1 showed that 55.3 
per cent, presented symptoms referable to the stomach. It appears, 
however, that these gastric disturbances were in no way due to changes 
in the stomach peculiar to tuberculosis itself; the changes being such 
as might occur in any chronic wasting disease. Janowski 2 reports that 
among 700 patients, 35 per cent, suffered from gastric disturbances, 
which were more often encountered in women than in men. With this 
Kuthy is also in agreement. He found that in 37.3 per cent, of his 
male patients there were gastric disturbances, as against 50.1 per 
cent, in his female patients. In the first stage, 38 per cent.; in the 
second stage, 46.4 per cent.; and in the third stage 57.2 per cent, 
showed these symptoms. 

Symptomatology. — One of the characteristics of the anorexia of phthisis 
is that, unlike the appetite in other diseases, it is independent of the fever, 
in many cases. Many patients with but slight fever have an almost 
complete antipathy for food, while others, who have moderate fever, 
preserve an excellent appetite. Lasegue said, "All patients who eat and 
digest their food well, despite having fever, are consumptives." In 
acute pneumonic phthisis, which is often difficult to differentiate from 
lobar or lobular pneumonia, I have placed great reliance on this 
symptom: In pneumonia the anorexia is invariably complete, while 
in acute phthisis the appetite may be retained more or less, and in 
spite of a temperature of 103° or 104° F. the patient is apt to ask for 
nourishment. 

In incipient phthisis the appetite is often very capricious. One 
day a certain food is preferred, while the next it is despised. Morbid 
cravings are not uncommon, especially in women. A large proportion 
of patients cannot tolerate certain kinds of food — some will not eat 
meat, others refuse milk, eggs, etc. It seems to me, however, that the 
repugnance for milk and eggs is often not the result of the tuberculous 
process, but is an acquired characteristic, due to the stuffing with these 
articles of food which is so commonly carried to an extreme degree. 
Following the usual advice, "plenty of milk and eggs," is likely to 

1 Tr. Nat. Assn. Study and Prevent. Tuberc, 1910, vi, 193. 

2 Ztschr. f. Tuberk,, 1907, x, 493. 



GASTRO-INTESTINAL SYMPTOMS 225 

ruin an excellent appetite, if carried to extremes. Two or three quarts 
of milk, and half or one dozen raw eggs daily, which tuberculous 
patients often consume, may result in a strong repugnance to these 
articles. 

An aversion to fats of any kind is very frequently observed in phthisical 
patients. Hutchinson noted this fact over sixty years ago, and stated 
that 71 per cent, of his phthisical patients disliked fats; 33 per cent, 
could take them in but small quantities; while only 5 per cent, liked 
them. Fenwick noted a marked aversion to fat in 64 per cent., and 
many of his patients developed this peculiar antipathy many months, 
or even years, before the onset of the pulmonary disease. He observed 
that among families which exhibit a marked predisposition to tuber- 
culosis, it is not uncommon to find that several members possess a 
strong aversion to all forms of fat and are often unable to partake of 
even a small quantity of this material without suffering from acidity, 
nausea, or attacks of biliousness. Occasionally we meet with tuber- 
culous patients who dislike carbohydrate, and especially saccharine, 
foods, the ingestion of which causes more or less severe gastric dis- 
comfort. 

In many cases the anorexia improves with the improvement in the 
local condition in the lung; but we also meet with cases in which the 
tuberculous lesion is slowly progressing or quiescent, but the appetite 
improves, as if the organism had adapted itself to the tuberculous 
toxemia. In fact, almost insatiable hunger may be seen on rare 
occasions. 

In the early stages of phthisis digestion is fair, or good, in most cases. 
Indeed, it appears to me that digestion in phthisis usually depends on 
the condition of the g astro-intestinal tract before the onset of the king 
disease. As was already intimated, the excessive quantities of milk 
and raw eggs may be responsible for the symptoms of dyspepsia in 
many cases, such as pyrosis, belching, flatulence, bad taste in the 
mouth, etc. The fact that these symptoms may be removed by appro- 
priate corrections in the diet is in favor of our contention. Excepting 
in advanced cases, and in alcoholics, vomiting, if it occurs at this stage, 
is due to cough, as has already been detailed when speaking of the 
emetic cough. In the advanced cases it is likely to be preceded by 
nausea, which is not the fact with the emetic cough. 

Causes of Anorexia. — It appears that the anorexia of phthisis is of 
toxic origin. Analyses of the gastric contents have not revealed any 
constant changes in the anatomy or functional activity of the stomach 
in the early stages of phthisis. In some cases hyperchlorhydria is 
found, in others hypochlorhydria, while in many others the free and 
combined acids remain in about normal proportions. Nor have any 
constant secretory or motor disturbances been observed. The physi- 
ology and pathology of the stomach in early phthisis, as studied by 
Klemperer, Hayem, Einhorn, Brieger, Fenwick, and others, show no 
characteristic functional changes. 
15 



226 DISTURBANCES IN GASTRO-INTESTINAL TRACT 

Many French authors, notably Marfan, 1 are of the opinion that 
the gastric symptoms in early phthisis are due to the general anemia 
which causes sluggish secretion of gastric juice, weakness of the smooth 
musculature, and hyperesthesia of the gastric nerve endings of the 
vagus. Fenwick, finding that the dyspepsia in phthisis is not a direct 
resultjof pyrexia, nor of direct irritation of the mucous membrane, 
concludes that it is probably due to the chronic absorption of certain 
toxic substances which are manufactured in the pulmonary cavities; 
but he describes a form of dyspepsia which often precedes the develop- 
ment of pulmonary tuberculosis, when cavities are out of the question. 

The gastric symptoms appear to be analogous with those observed 
in chlorosis, and the severe anemias, which cause ischemia of the diges- 
tive tract. But, as Janowski points out, many tuberculous patients 
without any anemia also suffer from gastric symptoms, and he con- 
cludes therefore that the anorexia is not invariably due to general 
anemia, but to ischemia of the gastric and intestinal mucosa. This 
explains why so many different results have been obtained from 
analyses of the gastric contents. It is the paroxysmal proclivity of 
the gastric disturbances which is characteristic of early phthisis. 

Gastric Symptoms in Advanced Phthisis. — The anorexia and other 
gastric symptoms of early phthisis usually subside in cases pursuing 
a favorable course and the patients recover. But in cases with pro- 
gressive disease, especially those characterized by pulmonary excava- 
tions, more or less severe symptoms of dyspepsia are present. Nearly 
a century ago Louis found that about two-thirds of his phthisical 
patients had shown signs of dilatation of the stomach. W. Soltau 
Fenwick found among 100 autopsies in cases of tuberculosis in which 
he took special notes on this point, that the lower margin of the viscus 
extended below the level of the navel in 64, and he says that it is rare 
while performing an autopsy on a phthisical subject to fail to encounter 
some increase in the dimensions of this viscus. The degree of gas- 
trectasis appears to bear a direct relation to the extent and chronicity 
of the pulmonary lesion. 

Chronic catarrh is very frequent, but true tuberculous ulcers are 
exceedingly rare, probably because the stomach contains very little 
lymphoid tissue, and bacilli cannot reach there through this channel, 
and the acid secretions are inimical to the growth of tubercle bacilli. 
Fenwick, after a careful search, was able to discover the records of 24 
cases of this affection, several of which are, however, open to suspicion ; 
while among the notes of 2000 necropsies on cases of phthisis performed 
at the Brompton Hospital he could find only two instances in which 
tuberculous ulcers of the stomach were discovered. Lauritz found 
4 cases of undoubted tuberculous ulcers in the stomach among 580; 
Melchior 6 in 848 autopsies, and Gassmann 6.13 per cent, in 600 
autopsies. Mohler and Funk did not find a single instance of gastric 

1 Troubles et lesions gastriques dans la phtisie pulmonaire, Paris, 1887. 



GASTRO-INTESTINAL SYMPTOMS 227 

ulcer in 85 autopsies. There have been reported cases of perforation 
of tuberculous gastric ulcers into the peritoneum, though this is exceed- 
ingly rare because of the inflammatory adhesions which usually form 
around the ulcers and the peritoneum. Simple gastric ulcers are not 
infrequently found at autopsies on tuberculous bodies, but the propor- 
tion is not higher than among patients who succumbed to any cause. 

In the vast majority of cases of advanced phthisis the appetite is 
poor; those who do attempt to eat usually display various distastes 
for certain foods, and even this is not constant — the appetite is often 
very capricious, and many develop morbid cravings. This is one 
of the difficulties of feeding phthisical patients in sanatoriums and 
hospitals. At times we meet with patients who retain an excellent 
appetite to the end and cases of bulimia are not unknown. Pain after 
eating, pyrosis, belching, etc., are very common, and vomiting is at 
times a prominent symptom. But while the emetic cough may be 
encountered in advanced cases, the vomiting at this stage is usually 
not of this type. They simply vomit because of gastritis, or dilatation 
of the stomach. This type of vomiting is usually preceded by nausea, 
belching, etc., and not by cough as in those having the emetic cough. 
The nausea and retching may persist for several hours after the vomit- 
ing and the ejecta consist of sour food mixed with mucus. I have met 
with cases in which no food could be retained owing to vomiting, and 
some even with hematemesis. The prognosis in these cases is gloomy 
indeed. 

In hectic cases the gastritis is often very troublesome and, com- 
bined with vomiting, nightsweats, cough, diarrhea, etc., it is one of the 
terminal symptoms of phthisis. In many cases, however, the pul- 
monary symptoms overshadow the gastric phenomena, but very often 
the latter are sufficiently pronounced to require great care and atten- 
tion. The amyloid liver often contributes considerably to the digestive 
disturbances, and lardaceous changes in the bloodvessels of the stomach 
are not unknown. I have met with cases of this type, extremely 
emaciated, hardly able to move a limb, yet they asked for food which, 
when given by the nurse, was relished with an apparently voracious 
appetite. 

It appears that the dyspepsia of advanced phthisis is usually asso- 
ciated with pulmonary excavation, and is mainly caused by the pro- 
longed intoxication characteristic of progressive and advanced disease. 
A fruitful source of gastric derangement is swallowed sputum, more 
common in women. The sputum not only irritates the mucous mem- 
brane of the gastro-intestinal tract, but it is also absorbed and pro- 
duces toxemia. The mucous membrane of the gastro-intestinal tract 
eliminates poisons from the blood, which in their turn irritate these 
membranes, as is the case in acute mercurial poisoning in which mer- 
curial albuminates circulating in the blood are eliminated into the 
intestines where they cause severe diarrhea. The injection of large 
doses of tuberculin may also cause diarrhea. 



228 DISTURBANCES IN GASTRO-INTESTINAL TRACT 

Intestinal Symptoms. — During the incipient stage of phthisis the 
bowels are unaffected in most cases, though we meet with constipation 
in a large proportion of cases. But I doubt whether the proportion is 
higher than among people with modern habits of life and dietetic 
conditions. In some cases the constipation is due to the sedative 
medication used for the control of the cough. 

Diarrhea may be one of the symptoms of incipient tuberculosis. 
It is met with mainly in patients at the two extremes of life — in chil- 
dren under ten years of age and in senile patients. In children the 
diarrhea may be the only symptom, while examination of the chest 
may show nothing conclusive, or signs of tracheobronchial adenopathy 
may be found. In aged patients who have felt quite well, even claim- 
ing that they have not coughed, a chronic and persistent diarrhea 
should be considered a sign that a careful examination of the chest is 
urgent. It will be found that there are signs of old phthisical lesions 
in the lungs, and the sputum may contain numerous tubercle bacilli. 
Very rarely diarrhea is one of the symptoms of incipient phthisis in 
young adults. 

In some patients the functions of the bowels remain more or less 
normal through the course of the disease, but this is rare. In most 
cases diarrhea makes its appearance with the advance of the disease. 
While in many cases it is due to tuberculous ulceration of the bowels, 
there are others in which it is caused by intestinal catarrh, very fre- 
quently the result of dietetic erors. In many the ingestion of large 
quantities of milk is responsible and eliminating milk from the diet 
promptly gives relief. In others the excessive amount of fat, mainly 
eggs, is responsible. Elsewhere it is pointed out that raw eggs are very 
frequently the cause of diarrhea (see Chapter XXXVIII). Persons 
who have had intestinal trouble before the onset of phthisis are more 
liable to suffer from catarrhal diarrhea than others. As will be pointed 
out later when speaking of tuberculous ulceration of the intestine, the 
differential diagnosis is exceedingly difficult. The prognosis depends 
on the causation of the diarrhea. When due to amyloid degeneration 
or tuberculous ulceration of the intestines the prognosis is grave. 

EMACIATION. 

Emaciation is a cardinal symptom of phthisis; one of the triad 
mentioned by Richard Morton, the others being cough and fever. 
Popular lore, as well as medical experience, have always associated 
tuberculosis with emaciation. Phthisis (Greek, i/'flioic), consumption, 
has its equivalent in every European language. That it is mainly 
due to the tuberculous toxemia, engendered by the metabolism of the 
tubercle bacilli, is evident from the fact that experimental tuberculosis 
is always accompanied by emaciation of the animals. 

In acute galloping consumption, and in miliary tuberculosis, the 
emaciation is progressive and frightful, much more rapid than in other 



EMACIATION 229 

febrile diseases, as pneumonia., typhoid, etc., and this is one of the most 
important points in the differentiation of acute tuberculosis from other 
acute diseases. In children, when during or after an attack of measles, 
pertussis, etc., the wasting becomes very marked and there is dyspnea, 
rapid pulse, etc., acute tuberculosis is to be suspected. 

While the denutrition and wasting in phthisis is often caused, and 
always enhanced to a certain extent, by the gastro-intestinal disturb- 
ances which are concomitants of the disease in all its stages, we meet 
with emaciation almost constantly in active disease w T ith fair gastro- 
intestinal functions. Some authors are inclined to attribute the ema- 
ciation to the lowered powers of absorption caused by a congenital 
narrowing of the lymph channels in the intestinal tract which is said 
to predispose to phthisis. But this has not been proved. 

Extent of Emaciation. — Not only is the subcutaneous adipose 
tissue wasting, but the nitrogen-containing muscles also vanish with 
astonishing rapidity. It is noteworthy that the first muscles to tcaste 
are those of the thorax — the pectorales, the scapular, the intercostals, 
etc. In many incipient cases we see a striking contrast between the 
wasted and flabby muscles of the chest — and in women occasionally 
the wasted breasts — and the fairly preserved contour of the muscles 
on the extremities. Moreover, the muscles and subcutaneous tissue 
of the affected side of the chest waste earlier than those on the opposite 
and unaffected side. The result is that the supraclavicular and supra- 
spinous fossae are more or less deeply excavated. This characteristic 
of the muscular wasting has recently been made available for diagnosis 
by the excellent studies of Pottenger. In some early cases the face 
remains full and is thus apt to deceive as to the state of nutrition of 
the patient whose trunk and abdomen are markedly emaciated. 

Effects of Emaciation. — The weakness, weariness, loss of strength 
and vigor of the consumptive are greatly due to the muscular atrophy 
even in the early stages of the disease, and one of the best signs of 
improvement is the regression in the muscular atrophy. There 
appears to be a direct relation between emaciation and the course 
of the disease. With each extension of the process in the lung, with 
each hemorrhage, he loses in weight, and with each inprovement he 
gains in this direction, while in quiescent cases the weight remains 
unaltered. It may be stated that, with some exceptions to be men- 
tioned later, the scale may be taken as a fair index of the evolution 
of phthisis, and when we consider it in connection with the tempera- 
ture curve, we can follow the case and interpret it from the prognostic 
standpoint with a fair degree of safety. 

There are, however, exceptions: Patients in whom tbe disease has 
been arrested, i. e., in whom a quiescent lesion is smouldering, are apt 
to remain underweight indefinitely, though they feel quite well, and 
are more or less efficient. 

When patients are progressively losing it is not advisable to tell 
them the extent of their denutrition. The discouragement often pulls 



230 DISTURBANCES IN G ASTRO-INTESTINAL TRACT 

them down much further. Conversely, it is often observed that 
patients gain weight after changing their physician, entering a new 
sanatorium, etc., and thus gain a false impression that they are on 
the road to recovery. But after the novelty of the new surroundings 
has worn oft', the gain ceases. They may then even lose progressively, 
and finally weigh less than before admission to the institution. To be 
of favorable prognostic significance, gain in weight must be persistent 
for several months. 

In some cases of phthisis the emaciation is rapid and extreme; 
within a few months the body of the victim is reduced to a skeleton. 
These are the cases in which the disease runs an acute and progressive 
course — galloping consumption. Xow and then we meet with patients 
in whom the disease is chronic, lasting for many years, still the emacia- 
tion is severe; the ribs, robbed of their adipose covering, protrude 
between the atrophied intercostal muscles so that we are unable to 
adapt the bell of the stethoscope to the chest. This cachectic form of 
phthisis is mostly seen in old people and, inasmuch as they have no 
fever and hardly cough, latent cancer is at times erroneously diagnos- 
ticated. 

Prognostic Significance of Emaciation. — Sanatoriums advertising 
their advantages usually show the average number of pounds gained by 
the patients during a certain period, and patients usually gauge their 
progress by the scale. This is correct in the vast majority of cases. 
An improving patient is one who gains in weight, and one who lose> 
progressively is doomed. But to this there are exceptions. Gains in 
institutions, while the patient is under a rigorous rest cure and overfed 
for long periods, are good as far as they go. But in order that the 
patient should be pronounced improved, or cured, it is necessary that 
he should hold his gain after he becomes active at his occupation or 
at some other vocation which suits him. In this regard, the graduated 
labor system of Paterson at Fromley is superior to other forms of 
institutional treatment. The gains attained at Fromley are said to be 
more lasting than those in the institutions where the inmates lead a 
lazy or indolent life. Similarly, patients who are treated at home, and 
allowed to do some work while under treatment, are more likely to keep 
their gains than the former class. 

We must be careful hi evaluating gams in weight. Sometimes the 
patient keeps on gaining moderately while the disease is progressing 
and we wonder why this is so. A careful investigation may show that 
the lower limbs are edematous, and it is not fat and flesh which is 
responsible for the increase in weight, but dropsical fluid. 

At times we meet with patients in whom the lesion in the lungs is 
improving or stationary and they have a good, or even a voracious, 
appetite, yet they keep on losing in weight. This is usually due to 
intestinal tuberculosis in which there may not be the characteristic 
diarrhea. This is a diagnostic point worth remembering, because it 
is often very difficult to decide whether the intestine is implicated in 



EMACIATION 231 

the process, and the prognosis depends so much on the condition of 
the bowels. 

Seasonal Influences. — The seasonal influences on the weight of con- 
sumptives are best studied in sanatoriums. It appears that there are 
significant differences in this regard. At North Reading, Mass., Burns 1 
found that the minimum amount of weight loss occurs in the colder 
months; the maximum loss occurs in the warmer months; and rapid 
increase in amount of emaciation appears during the spring months. 
Going hand-in-hand with this is the fact that deaths in July out-number 
all other months. At the Adirondack Cottage Sanitarium, Brown 2 
found that the weight curve in pulmonary tuberculosis, if not influenced 
by change of climate or some other factors, rises from August to 
Christmas (sometimes to November), remains more or less stationary 
with minor fluctuations from Christmas to Easter (March) , and sinks 
gradually from Easter to August. Brown adds that this corresponds 
closely to the normal weight curve. In Pennsylvania Karl Schaffle 
finds the gains most marked during the fall and winter months. Among 
private patients in New York City I find that the summer months are 
not conducive to gains in weight, nor are the autumn months with their 
variable weather; but during the winter, especially during very cold 
seasons, the gains are extraordinary; even patients who are running 
low from one reason or another often gain somewhat, or remain 
stationary, during December, January, and February. 

This is not true of other climatic regions. In a careful study of the 
weights of consumptives in eight sanatoriums in Denmark, N. S., 
Strandgaard 3 found that weekly weighing shows low gains during the 
winter and spring months from December to May. Then there is a 
distinct rise during the summer months, June, July, and August, reach- 
ing its maximum in September, and declining in October, and more 
so in November and reaching its minimum in December. This is the 
exact opposite of conditions in the United States. 

The subject deserves careful study in connection with meteorological 
conditions. 

Fat Consumption. — The term "fat consumption" may appear 
incongruous, but we meet with cases of active phthisis in which the 
panniculus adiposus is well preserved, or even with excessive obesity, 
the phthisiques gras of some French writers. I see several cases of 
this sort annually in my private and hospital work. They appear 
healthy, with florid cheeks and well-formed bodies, and their only 
trouble is that nobody believes they are tuberculous. They cough 
and expectorate, often profusely, quantities of sputum reeking with 
tubercle bacilli, run a mild subfebrile temperature, at times have 
nightsweats. Many have more or less profuse hemoptysis and in 
two that were under my care the cause of death was copious terminal 
hemorrhage. 

1 Boston Med. and Surg. Jour., 1914, clxx, 564. 2 Osier's Modern Medicine, i, 380. 
3 Beitr. z. klin. d. Tuberk., 1914, xxxii, 179. 



232 DISTURBANCES IN G ASTRO-INTESTINAL TRACT 

When these patients present themselves for examination one is 
loath to make a diagnosis of phthisis even when physical exploration 
of the chest reveals a typical lesion in one or both lungs, or cavitation, 
which is not uncommon. The course of the disease is rather slow; 
we may follow them for years without noting any marked changes in 
their general condition despite the fact that the lesion in the lungs is 
progressing and excavations are -forming. Of course, only positive 
sputum findings are convincing to some patients or even physicians. 

The obesity is mostly seen in female consumptives, though I have 
met it in males, especially alcoholics and those having a history of 
syphilis. They usually have a voracious appetite and when told that 
they must eat well, they follow directions, often overdoing it. Com- 
bined with the rest which is urged and implicitly obeyed, the overfeed- 
ing is effective in producing fat, despite the activity of the disease. In 
tuberculosis implanted on pulmonary emphysema, and also in fibroid 
phthisis, the weight of the patients is often above the average, though 
real obesity is observed only rarely. 

Fat consumption is also observed in children, especially infants of 
tuberculous stock. They appear well nourished and fat, but when 
we examine their muscles we find them flaccid and soft. These " pasty" 
infants have no resistance against infection, and are carried off by any 
acute disease which flares up the dormant tuberculous lesions. Simi- 
larly, tuberculous meningitis and bronchopneumonia are often seen 
in rather fat children. 

THE SKIN. 

In addition to the wasting of the muscles and subcutaneous fat, 
atrophy of the skin is one of the early changes in phthisis, first 
described by Clarence L. Wheaton, 1 of Chicago, and then by Pottenger. 
On inspection it is noted that the skin over the site of the lesion is 
thin and the subcutaneous tissue vanished. According to Pottenger, 
this is part and parcel of the general degeneration, and occurs after 
the process has existed for some time. It denotes chronicity rather 
than earliness, although it is often found over comparatively early 
tuberculous processes. In such cases it may be presumed that there 
was an old quiescent lesion which has become the seat of renewed 
activity. 

The complexion of the consumptive is usually pale, though at times 
we meet with patients advanced in the disease who have retained a 
florid color. In some the hectic flush is evident at first sight; it is 
mostly seen at the time when the daily rise in temperature occurs. 
Occasionally this redness appears only on one cheek, corresponding 
usually to the affected side of the lung, as is discussed elsewhere. In 
fibroid phthisis, and in those with emphysema, in the advanced stages 
of which dilatation of the right heart occurs at times, there may be 

1 Jour. Am. Med. Assn., 1910, liv, 2123. 



THE SKIN 233 

cyanosis of variable degree. In many eases with extensive excavations 
in both lungs there is hardly any cyanosis, at most some livid tint of the 
lips may be elicited on careful observation, but in fibroid phthisis the 
cyanosis is frequently marked. In far-advanced disease with amyloid 
changes, the skin shows the characteristic appearance of this condition. 
According to Meyer Solis-Cohen 1 between 25 and 33 per cent, of tuber- 
culous patients exhibit flushing, burning, sweating, urticaria; between 
14 and 25 per cent, subjective sensations of heat, angioneurotic edema, 
dermographia, etc., all of which he attributes to autonomic disturb- 
ance. 

Chloasma Phthisicorum. — Smooth, shining, and non-desquamat- 
ing, yellowish-brown spots are occasionally seen quite early in the 
disease on the forehead and upper parts of the face. They are fre- 
quently single, but often confluent, forming large patches which in 
female patients may be a great source of annoyance. My experience 
with consumptives confirms the observation made long ago by Jeannin 
to the effect that chloasma phthisicorum is mostly seen in connection 
with enlarged glands, and that these patients only rarely suffer from 
hemoptysis. In fact, I have looked in all cases of hemorrhage that 
have come under my observation during the past five years and found 
no one with this eruption of the skin, while among my other patients 
it is quite frequent. In advanced cases we often meet with brownish 
coloration of the skin, mostly marked on the face, but at times all 
over the body, simulating the smoky gray or bronze color seen in 
Addison's disease. Considering the frequency with which the adrenals 
are found affected in consumptives, we have an explanation for this 
phenomenon. 

Patients who sweat profusely may show miliaria, or sudamina, on 
the chest and abdomen. Herpes zoster of the trunk and limbs may 
also occur, mostly in patients with caries of the spine. 

Pityriasis Tabescentium. — In more or less advanced cases other 
skin eruptions are often seen which are, within certain limits, charac- 
teristic of phthisis. In those who sweat profusely the atrophied skin 
is during the day dry, pale, and brittle, and the upper epidermic layer 
desquamates and sheds yellow or gray scales. In some cases it looks 
as if the skin was covered with dust. It is known as pityriasis tabes- 
centium and occurs mostly in consumptives who are not extremely 
emaciated, but who have excessive secretion of sweat and sebum; it 
is localized over the chest anteriorly and posteriorly, but at times the 
entire body is covered with it. It may be seen in other wasting diseases, 
but most often in phthisis. 

Pityriasis Versicolor. — This is even more often seen in phthisis. 
The eruption is discretely scattered over the anterior and posterior 
aspects of the thorax, and consists of small macules, slightly raised 
above the level of the skin, round or oval in shape with well-defined 

1 Am. Revue Tuberc, 1917, i, 289. 



234 DISTURBANCES IN G ASTRO-INTESTINAL TRACT 

margins. Scales can be scratched off and when examined' show 
roundish, shining microscopic spores, the Micros poron furfur. 

The color of the eruption varies in different individuals, but is 
mostly brown, or a dirty yellow, darker in those who lead an outdoor 
life, and over the arms and neck when these are affected, while in 
negroes they are almost white. In patients who neglect to attend to 
cleanliness of their bodies the macules may coalesce, forming large, 
irregular plaques covering large tracts of skin anteriorly and poste- 
riorly, which desquamate upon scratching. 

It is seen in consumptives who sweat profusely at night, which 
favors the growth of the fungi, and in patients whose skin has a ten- 
dency to scale, which assists in their detachment. Piery 1 has inoculated 
guinea-pigs with the scales removed from such patients and obtained 
positive results, and he suggests that it is a tuberculous dermato- 
mycosis. 

When seen on the chest, pityriasis versicolor is fairly indicative of 
phthisis, although it occurs in other cachectic diseases, notably cancer. 

We also meet with acnitis and folliclis, characterized by the eruption 
of red or dark brown nodules over the face, and more often over the 
back between the shoulder-blades and over them. W 7 e find these 
nodules in various stages of development, some becoming pustular 
and when the pus is discharged an ulcer remains, which heals, leaving 
a scar. They are found in exceedingly chronic cases. It has been my 
impression that the administration of creosote and arsenic and their 
derivatives is effective in enhancing these eruptions. 

The Hair. — Many authors have stated that alopecia is more fre- 
quent in phthisical subjects than in others, and it has been attributed 
to the same causes as those acting when the hair falls out after an 
attack of typhoid fever, etc. But in my experience this is not true. 
The tuberculous patients in my hospital and private practice are 
not more often bald than others of the same class, nor do I meet with 
many consumptives who have localized alopecia, or alopecia areata. 
Premature grayness of the hair, which Cornet mentions as very fre- 
quent among consumptives, has also not been found by me to be 
frequent in tuberculous patients in the United States. - 

Clubbed Fingers. — Clubbed fingers were already mentioned by 
Hippocrates as a symptom of phthisis, and French writers at present 
call them doigts hippocratiques. They are found in about one-third 
of advanced consumptives, and are probably caused by chronic 
peripheral passive congestion. Clubbed fingers are not exclusively met 
with in phthisis, but also in empyema, bronchiectasis, chronic bron- 
chitis, asthma, and pulmonary emphysema, in thoracic aneurysms, 
etc. They have also been encountered in rare cases of cirrhosis of 
the liver and amyloid disease. 

In phthisis we usually find that the fingers of both hands are thick- 

1 Gaz. d. hop., 1912, lxxxv, 531. 



THE SKIN 



235 



ened and bulbous, like a club or drumstick, resembling somewhat 
the condition seen in chronic onychia. The terminal phalanges are 
enlarged, the nails curved longitudinally and laterally. From radio- 
scopic studies it appears that the bones and joints are not affected, 




Clubbed fingers and curved nails. 



nor is the skin altered in any way, but only the superficial soft parts 
are hypertrophied. As to what the change consists in we are in ignor- 
ance because of lack of anatomical and histological studies. Some 
have suggested that it is a fibrous thickening of the innermost layers 
of the epidermis, as a result of prolonged congestion of the capillaries. 




Fig. 31. — Clubbed fingers in phthisis. 



This may be true of some cases, but in those in which the condition 
develops within a few weeks it is doubtful whether this could be the 
actual anatomical change. 

In most cases the onset is slow and insidious and the patient knows 



236 



DISTURBANCES IN GASTRO-INTESTINAL TRACT 



■Br - 




r .Kj^M^iH 


'' ■• \ \ \^k3 


h^^^L 





Fig. 32. — Changes in the toes in tuberculous osteo-arthropathy. 




Fig. 33. — Radiogram of a hand in a case of clubbed fingers in pulmonary osteo- 
arthropathy with bronchiectasis and pulmonary emphysema. On the tips of the end 
phalanges marked cauliflower formations; bony excrescences on basal portion of some 
phalanges; typical Heberden's nodes; broadening of the bases of the middle phalanges. 



THE SKIN 



237 



nothing about it until the physician calls his attention to the clubbed 
fingers. But on rare occasions, as has already been noted by Trous- 
seau, it comes on very quickly and within a few weeks the fingers look 
like drumsticks. In these acute cases they may be painful, tender, 
and livid. Lividity is also seen in those suffering from pulmonary 
emphysema or fibroid phthisis. The nails are curved and look like 
claws. 




Radiograms of hand in a case of fibroid phthisis. 



My observations are in agreement with those of Bezancon 1 that 
clubbed fingers are not met with in all cases of chronic phthisis, as 
some have stated. A large number of consumptives have normal- 
shaped fingers, while some have even long, tapering terminal phalanges. 
Clubbed fingers are encountered almost exclusively in fibroid phthisis, 
pulmonary emphysema with tuberculosis and in those having exten- 
sive pleural adhesions. In other words, whenever clubbed fingers 
are encountered in a case of phthisis we find that the patient is also 
suffering from dyspnea and dilatation of the right heart. This would 
suggest mechanical disturbances of the circulation, causing peripheral 
venous stasis. Moreover, the prognosis in these cases is quite favor- 



Arch, gen. de med., 1904, i, 1663; ii, 3100. 



238 DISTURBANCES IN GASTRO-INTESTINAL TRACT 

able as regards duration of life, though the outlook as to comfort is 
rather gloomy. 

Pulmonary Osteo-arthropathy. — In some chronic cases we meet 
with enlarged hands simulating those seen in acromegaly. The fingers 
are altogether increased in volume, the nails enlarged and curved like 
the beak of a parrot. The metacarpophalangeal region is usually 
normal, but the wrist is enlarged and deformed, bulging on its dorsal 
aspect. In many cases there is also some deformity of the spine — 
kyphoscoliosis, and the feet may show the same changes as the wrists 
and hands, especially the toes and tarsus. In the cases that came 
under my observation there were pains of variable severity, some- 
times unbearable and generally intermittent. As can be seen from 
the radiograms (Figs. 33 and 34), the differences between pulmonary 
osteo-arthropathy and simple clubbed fingers consists in this: In the 
former the bones and joints are hypertrophied and some osteophytes 
may be seen at the line of the joint cartilages, while in the latter only 
the soft parts are implicated, the bones remaining practically normal. 
In his recent thorough study of this subject, Edwin A. Locke, 1 is 
inclined to regard clubbed fingers in phthisical patients as identical 
with osteo-arthropathy, the former representing an early stage of the 
latter. He also found with clubbed fingers early proliferative changes 
in the periosteum of some of the long bones of the forearm and lower 
legs of exactly the same type as in hypertrophic osteo-arthropathy. 
Clinically we distinguish these two conditions by the fact that in 
clubbed fingers only the terminal phalanges are enlarged, while in 
osteo-arthropathy the wrist is also affected, and the feet usually show 
the same changes and in addition there is in most cases decided spinal 
deformity. But this does not exclude the identity of the two processes 
if we choose to regard clubbed fingers as the early stage of osteo- 
arthropathy. The former is, however, far more common. 

1 Arch. Int. Med., 1915, xv, 659. 



CHAPTER XII. 

SYMPTOMS REFERABLE TO THE CARDIOVASCULAR AND 
RENAL SYSTEMS. 

THE CARDIOVASCULAR SYSTEM. 

Cardiac Palpitation. — Of the functional cardiovascular disturbances 
in phthisis the most important are palpitation, tachycardia, and hypo- 
tension. They are very often associated, but at times we meet one to 
the exclusion of the other. 

In incipient cases palpitation is mainly met with in young persons, 
especially chlorotic girls. Slight or moderate exertion, excitement, and 
emotional disturbances may cause an attack, or it may occur without 
any provocation. At times it is very pronounced, and is perhaps the 
only subjective symptom which induced the patient to consult a 
physician. Rarely it is very severe and is accompanied by precordial 
pains and distress and by vasomotor disturbances, such as pallor, or 
flushing of the face, sweating, etc. 

I have met with cases in which palpitation preceded all subjective 
and objective symptoms of incipient phthisis. Some are for this reason 
treated for heart disease. As will be shown when speaking of the 
differential diagnosis of phthisis, the syndrome known as hyper- 
thyroidism is often mistaken for tuberculosis. The reverse is also true : 
Very frequently the rapid pulse, the tendency to sweating and flushes, 
emaciation, etc., are erroneously considered symptoms of hyper- 
function of the thyroid, and treated as such. A careful examination 
of the chest, however, will reveal a tuberculous lesion. 

The causes of the palpitation at this stage are not clear. Some have 
been inclined to attribute it to dilatation of the right heart, but we 
meet it in cases in which this organ is normal. Others believe it is 
due to the anemia — low arterial tension — or to sympathetic nerve 
disturbances. The last factor is apparently operative in many cases, 
because we meet it mostly in nervous patients, in young girls and in 
women during the menopause. Compression of the vagus by enlarged 
glands may be the cause in some cases. 

Cardiac irritability is seen also in advanced but quiescent cases. 
The patient is doing well, has no fever, no cough and is not emaciated. 
But the least exertion, emotion, or complication provokes cardiac dis- 
tress which may be very painful, almost anginal. Here, the palpita- 
tion is, as a rule, due to cardiac dislocation, and occurs more often in 
left-sided lesions. A large cavity in the left lung with pulmonary con- 
traction has drawn the mediastinum to the left, and the diaphragm 






240 CARDIOVASCULAR AND RENAL SYSTEMS 

upward, so that the heart is pushed upward and to the left, and the 
apex beat may be found in the third interspace at the axillary line. In 
a recent case of this character I also found arrhythmia. The palpitation 
is not so pronounced in right-sided dislocations of the heart, not even 
in complete dextrocardia. 

Palpitation has no influence on the course of phthisis, excepting in the 
advanced stages when it is due to dislocation of the heart. In the early 
cases we may meet with annoying palpitation in nervous patients who 
are progressively improving. But from the diagnostic standpoint it is a 
symptom of great value. Hirtz said that " when a patient complains of 
palpitation, examine his lungs; and examine his heart when he com- 
plains of dyspnea." While this does not hold good in every case, yet 
it is well worth bearing in mind, especially when dealing with an anemic 
youth. In some cases of phthisis we meet with palpitation for a day or 
two before the occurrence of hemoptysis. 

Tachycardia. — Rapid heart action objectively ascertained — which may 
not be known to the patient at all, thus differing from palpitation, which 
is a subjective symptom — is very frequent in all stages of phthisis. In 
my experience, over 90 per cent, of cases of incipient phthisis have 
tachycardia which is usually permanent or, rarely, paroxysmal. It 
is a symptom of phthisis which is not appreciated to the extent it 
deserves, though it is often very helpful in deciding a doubtful case. 

The tachycardia may be of toxic origin. Every elevation of tem- 
perature in phthisis, as in other conditions, is accompanied by an 
acceleration in the pulse-rate. But it is often pronounced in those 
running a subfebrile temperature and also in afebrile cases. In fact, 
in tuberculosis the pulse is accelerated far out of proportion to the height 
of the temperature. In most other cases an elevation of 1° F. is usually 
accompanied by an increase in the pulse-rate of about eight beats per 
minute, while in phthisis we often have a temperature of 100° while the 
pulse counts 120 and even more. In fact, in most afebrile cases of 
phthisis the pulse is over 90 per minute and during the morning sub- 
normal temperature tachycardia is not at all rare. Thus tachycardia 
is an early symptom of phthisis and some writers consider it a premoni- 
tory symptom. 

Permanent Tachycardia. — In a large proportion of cases the tachy- 
cardia is permanent and accompanied by subjective discomfort, such 
as palpitation, languor, debility, dyspnea, etc. In others, it is purely 
objective; the patient is hardly aware of its presence. I have observed 
many cases in which the disease was arrested, or even cured, yet the 
tachycardia remained. At times it greatly interferes with the patient's 
efficiency. But I cannot agree with those who say that in an arrested 
case one cannot feel safe as to the continued progress of the patient so 
long as the pulse-rate remains high. I have seen patients who have 
been able to work for a living without much discomfort in spite of the 
rapid heart action. 

One characteristic of the pulse of the consumptive is its instability 



THE CARDIOVASCULAR SYSTEM 241 

and variability. While resting the rate may be normal, but the slightest 
exertion — a fit of coughing, some emotional experience, a heavy meal, 
or changing from the reclining to the erect posture — may send up the 
pulse rate to 110 or 120. Faisans maintained that he did not know 
of any disease in which the pulse is as unstable as in phthisis. 

Paroxysmal Tachycardia. — In rare cases we meet with paroxysmal 
tachycardia. The patient feels comparatively well and, without any 
exciting cause, he is seized with severe palpitation, dyspnea, or even 
orthopnea, and cyanosis. Counting the pulse-rate, we find it 150 to 
200 per minute, small, wiry and often irregular. The attack may 
last a few hours, a day or two. In one case the patient got an attack 
while in my office, the pulse going up from 96 to 160, and looked as if 
he was breathing his last. He recovered in two hours. There is at 
present in my wards at the Montefiore Hospital a young woman who 
often gets these attacks. In the beginning the rapid pulse, dyspnea, 
cyanosis, and prostration suggested the collapse characteristic of 
pneumothorax. Careful search for signs of air in the pleura proved 
negative. She gets these attacks at irregular intervals and recovers 
within a few hours or a day. 

After several attacks, which may come on at frequent intervals, 
we may observe signs of cardiac dilatation — the heart gives way and 
the result is edema of the lower extremities, enlargement of the liver, 
etc. Finally, asystole occurs and the patient succumbs. Paroxysmal 
tachycardia is of grave significance and, when occurring several times, 
will ultimately kill the patient during one of the attacks. 

Causes of Tachycardia. — The causes are obscure. It has been attri- 
buted to bulbar lesions, to interstitial neuritis of the pneumogastric 
nerve, and to myocarditis, etc. Some believe that it is due to compres- 
sion of the vagus by enlarged tracheobronchial glands, but it would 
seem that the effect should rather be a slowing of the pulse-rate, than 
an acceleration. Indeed, considering that the vagus is often pressed 
upon by enlarged glands, it is noteworthy that a slow pulse is exceed- 
ingly rare in phthisis. Other authors have attempted to explain this 
phenomenon by stating that it all depends on which part or branch of 
the pneumogastric is affected by the tuberculous process. On this also 
depends whether the stomach or myocardium will suffer. K. Bohland 1 
is inclined to ascribe the tachycardia in phthisis to the small heart 
characteristic of the disease — in order to pump enough blood into the 
system, the heart must beat more often. In the advanced stages of 
phthisis it is due to myocarditis. The tuberculous toxemia alone does 
not explain the tachycardia because it is found often in afebrile patients, 
as was already stated. 

Permanent tachycardia aggravates the prognosis of phthisis, and 
these patients should not be sent to a high altitude. The causes are 
complex and vary with each case. In patients in whom it is of toxic 

1 In Brauer, Schroder, and Blumenfeld's Handbuch der Tuber kulose, 1915, iv, 4. 
16 



242 CARDIOVASCULAR AND RENAL SYSTEMS 

origin we may expect improvement as soon as the fever subsides. But 
in many it is caused by compression of the pneumogastric nerve by 
enlarged tracheobronchial glands, neuritis of that nerve, or reflexly of 
gastric origin, fibrous degeneration of the cardiac muscle, or tuber- 
culosis or hyperf unction of 'the adrenals, etc. When due to cardiac 
displacement, especially to the left in left-sided lesions, it is permanent. 

Arrhythmia is only rarely observed in phthisis and the prognosis of 
these cases is rather unfavorable. 

Bradycardia. — A slow pulse is exceedingly rare in phthisis; those who 
see large numbers of these patients occasionally meet one with a 
pulse less than 50 per minute. One patient under my care had a pulse- 
rate of 36 per minute for several months, and only during febrile 
attacks did it rise to 50 or slightly more. Gueneau de Mussy, who 
described some of these cases, attributed it to irritation of the pneu- 
mogastric nerve. On the other hand, there are many physicians of 
large experience who have never seen bradycardia in phthisis. From 
the few cases met by me, it appears that the prognosis in phthisis 
with a slow pulse is very good. 

At the terminal stage of far-advanced phthisis we often meet with 
a slow, soft, almost imperceptible, pulse which intermits, indicating 
cardiac failure or exhaustion. The pulse is also slowed when meningeal 
irritation complicates the disease. 

Arterial Hypotension. — The blood-pressure, measured with a 
sphygmomanometer, is lower than normal in the vast majority of 
phthisical patients. It is evidently due to the toxic effects of the 
metabolic processes of the tubercle bacilli, because an injection of 
tuberculin is usually followed by a decided fall in the blood-pressure. 
Sir Douglas Powell says that the large doses of tuberculin which were 
used in the first days of Koch treatment of lupoid and other forms of 
tuberculosis caused severe collapse, and recent writers, like Levy, 
Geisbock, and others found that, even in small or moderate doses, 
tuberculin reduces arterial tension. It has been found that a low 
blood-pressure is an almost constant characteristic of the very early 
stages of phthisis and, when occurring in an adult without any other 
assignable cause, tuberculosis is to be suspected. John Ritter 1 found 
hypotension in cases of phthisis before the physical signs and even 
before elevation of temperature were definitely demonstrable. My 
own experience has brought me to the conclusion that in cases pre- 
senting obscure symptoms and signs of phthisis, when accompanied 
by a low blood-pressure, the diagnosis may be safely made; conversely, 
I always hesitate in cases with high arterial tension, excepting in 
persons over fifty years of age. But even in these high pressure is 
exceedingly rare in phthisis. 

This hypotension is quite marked in the early stages and becomes 
more accentuated with the progress of the disease. I find that, as a 

i Tr. Nat. Assn. Study and Prevent. Tuberc, 1911, vii, 297. 






THE BLOOD 243 

rule, cases of undoubted phthisis with a normal or high blood-pressure 
have a favorable prognosis. This is the case with phthisis in persons 
having interstitial nephritis, gout, pulmonary emphysema, etc.; they 
all have high blood-pressure, and the prognosis is favorable. When 
the blood-pressure is low at first but rises gradually, it is an excellent 
indication of improvement; conversely, tuberculous patients with 
normal or high blood-pressure who begin to show hypotension almost 
invariably also show indications of the extension of the process in the 
lung and the prognosis is aggravated. I have not noted in many cases 
any relation between the hypotension of phthisis and the temperature, 
the pulse-rate, or the dyspnea. It is met with in febrile and afebrile 
cases; in young and in the aged. 

It has also been observed by many authors that patients with a 
tendency to hemoptysis have a high blood-pressure which rises before 
the onset of the bleeding. At one time I tested this point in several 
patients but could not confirm it. Many who bled profusely had a 
very low blood-pressure. 

THE BLOOD. 

The Erythrocytes. — Despite the external appearance of anemia 
frequently seen in many phthisical patients in all stages of the disease 
— which has given rise to the expression "great white plague" — no 
changes in the cytology of the blood characteristic of the disease have 
been found. In fact, it is noteworthy that many patients who look 
pale show an almost normal blood picture. At times a polycythemia is 
encountered, but the hemoglobin is not increased under the circum- 
stances. Only on rare occasions have I found a decided decrease in 
the number of erythrocytes, especially during the very early, and 
very advanced, stages of the disease. In some few cases the count was 
as low as 1,000,000, or even less, but the fact that it is so rare shows 
that it is an accidental occurrence, and cannot be considered char- 
acteristic of the disease. After profuse pulmonary hemorrhages the 
anemia may be profound, but it is remarkable that the blood picture 
improves very rapidly after the cessation of bleeding. 

There is very often noted a decidedly low percentage of hemoglobin 
in incipient cases, even when the erythrocytes are not decreased in 
number. For this reason some authors have spoken of a pseudo- 
chlorotic blood picture. But soon after the patient is placed under 
proper dietetic and hygienic treatment the hemoglobin content of 
the blood improves, as a rule. It may be stated that in many cases 
there is slight diminution in the number of erythrocytes, and a pro- 
nounced diminution in the hemoglobin content, during the incipient 
and far-advanced stages of phthisis. 

From the researches of Limbeck, Grawitz, and others it appears 
that with the advance of the disease, even with the formation of 
pulmonary excavations, the blood picture is very often not deviating 
from the normal. The yellowish pallor, "ochrodermia," which is so 



244 CARDIOVASCULAR AND RENAL SYSTEMS 

frequent at this stage, is not due to alterations in the cytology of the 
blood, so far as can be ascertained. But there is good reason to believe 
that the total amount of blood in the body is less than in healthy 
individuals; that there is a distinct oligemia. This has been ascribed 
to the loss of water through profuse nightsweats, expectoration, and 
often diarrhea, which brings about a higher specific gravity of the 
blood with a concentration of the cells. 

In the far-advanced stages, with hectic fever, often complicated 
by mixed infection, there is, in addition to leukocytosis, a diminu- 
tion in the number of erythrocytes, with a fall in the percentage of 
hemoglobin. 

Leukocytes. — In incipient phthisis the leukocytes are quite normal 
in number and variety. Even in acute cases, so long as there is no 
mixed infection, the leukocyte count is unaffected. Some authors, 
notably Ullom and Craig 1 in this country, have found a slight leuko- 
cytosis which increases somewhat with the advance of the disease. 
But inasmuch as it only reaches about 11,000 to 14,000 on the average, 
it cannot be considered of any value diagnostically. Kjer-Petersen 2 
found that in women the number of white-blood cells oscillates between 
4000 and 25,000 under normal physiological conditions. 

Gerald B. Webb, G. B. Gilbert, and L. C. Haven 3 found the blood 
platelets are increased in number in cases of phthisis. In tuberculosis 
in guinea-pigs they observed the same phenomenon. They believe 
that the blood platelets either contain, or supply, opsonins. The fact 
that they are increased at an altitude of 6000 feet would, according 
to Webb, point to a reason for the salutary effects of high climates 
on phthisical patients. 

With the advance of the disease leukocytosis is not rare ; it is usually 
transient, but rarely permanent. It appears to depend on the activity 
of the tuberculous process, the intensity of the fever, the presence of 
complications, etc. But there are so many exceptions to this rule 
that it cannot be utilized for diagnostic and prognostic purposes. It 
appears, however, that an injection of tuberculin is usually followed by 
transient leukocytosis. Some have attempted to judge the presence 
of excavation by the white-cell picture, but have failed. Wright's 
attempt to utilize his tuberculo-opsonic index in the prognosis of 
tuberculosis has also failed to give satisfaction to most authors. 

Arneth's Blood Picture.— A great deal has been made during recent 
years of Arneth's blood work in infectious diseases, especially tuber- 
culosis. His theory is based on his observations of the growth of the 
neutrophile and the changes of the nuclei, or granules within these 
cells during the period. He developed a very complicated blood picture, 
based on the number of granules or fragments in each neutrophile. 
His contention is that when the disease takes a bad turn, there is an 
increase in the number of young forms of neutrophiles containing but 

1 Am. Jour. Med. Sc, 1905, cxxx, 386. 

2 Brauer's Beitr., 1906, Beiheft. 3 Arch. Int. Med., 1914, xiv, 743. 



THE BLOOD 245 

one granule as a nucleus, and a decrease in the older forms of cells 
which correspond to the polymorphonuclears of other writers; he 
calls it a shifting of the blood picture to the left. 

Arneth's work has been tested by many other authors and but very 
few have been able to confirm his contentions that the changes in the 
blood picture go hand-in-hand with the clinical course of the disease, 
nor have many agreed with his interpretation of the origin of the 
changes in the neutrophiles. In this country some authors have found 
Arneth's blood picture of value in diagnosis and prognosis, especially 
Minor and Ringer, 1 and James Alexander Miller and Margaret A. 
Reed. 2 Miller, in an exhaustive study of the leukocytes in tubercu- 
losis, arrives at the conclusion that it gives valuable information as to 
the prognosis and clinical course of phthisis, but in the diagnosis of 
incipient cases it is of no value. In his experience a leukocytosis, an 
increased percentage of small lymphocytes, a diminished percentage 
of eosinophiles, and a marked shifting of Arneth's blood picture to the 
left, are characteristic of cases of pulmonary tuberculosis which are 
progressively doing badly, or an exacerbation of the disease. 

I have given this method a trial and could find no diagnostic or 
prognostic hints which were constant; in fact, the contradictions 
were so frequent and notorious that I have abandoned it altogether. 
Pappenheim, Politzer, Hiller, and, in this country, M. Solis-Cohen, 3 
and Strickler and Kagan 4 have arrived at the same conclusion. 

Tubercle Bacilli in the Circulating Blood. — During recent years 
many investigators have found tubercle bacilli in the circulating blood 
of patients suffering from phthisis. Some have found them in the 
blood of patients with advanced forms of the disease, while others 
have even detected them in early cases. Rosenberger, 5 Koslow, 
Kurashige, and others, have even stated that in all cases of tubercu- 
losis, bacilli may be found when carefully looked for, while F. Klem- 
perer found them in 7 cases in which the disease w r as only suspected, 
but could not be diagnosticated with the usual clinical methods. 
But when still others, like Liebermeister, Suzuki and Takaki, and 
Kurashige, discovered tubercle bacilli in the blood of apparently 
healthy individuals, and Clara Kennerknecht in the blood of 91 per 
cent, of 120 healthy children, of which only 68 were tuberculous, the 
hopes entertained that we might have in this a good method of dis- - 
covering tuberculosis as a bacteremia before the onset of clinical 
symptoms began to vanish. The history of tuberculin as a diagnostic 
agent was here repeated. 

Further investigations by Walter V. Brehm, 6 Beitzke, Schern, and 
Dold have shown that there was a source of error: The tap water 

1 Am. Jour. Med. Sc., 1911, cxli, 638. ■ * Arch. Int. Med., 1912, ix, 609. 

3 New York Med. Jour., 1910, xcii, 248. 

4 Boston Med. and Surg. Jour., 1910, clxii, 709. 

5 Am. Jour. Med. Sc., 1909, cxxxvii, 267. 
« Jour. Am. Med. Assn., 1909, liii, 909. 



246 CARDIOVASCULAR AND RENAL SYSTEMS 

used in diluting the blood often contains acid-alcohol-fast rods which 
look like tubercle bacilli under the microscope. These acid-fast rods 
may be bacilli or some other substances, but they are not pathogenic 
to guinea-pigs. It has also been found that fragments of red-blood 
corpuscles may take on the stain of the tubercle bacillus and show 
acid-fast properties. 

These findings were verified in another way. The blood of tubercu- 
lous patients was injected into animals with a view of ascertaining the 
proportion that would be infected with tuberculosis. The results of 
some authors like Anderson/ Rumpf, 2 Ravenel and Smith, 3 Querner, 4 
Leo Kessel, 5 and others were entirely negative — none of the animals 
experimented on showed any tuberculous lesions, while others got a 
few positive results. Liebermeister, on the other hand, found that in 
6 cases the animals were infected with tubercle bacilli in the blood from 
human beings who showed no clinical symptoms of the disease. 

Recent investigations by Mildred C. Clough 6 show r that inoculation 
tests are unreliable, especially when the blood is taken from patients 
suffering from chronic phthisis. She has collected 1508 cases studied 
by guinea-pig inoculation, of which 195, or 12.9 per cent., gave positive 
results. In 500 cases Frankel 7 found 20 per cent, positives; Fischer 8 
in 1250 cases, 17 per cent. However, in all these cases acute and 
chronic tuberculosis were indiscriminately grouped together. In 48 
cases of miliary tuberculosis, 66.6 per cent, gave positive results. In 
other words, according to Clough, only 6.7 per cent, of chronic cases, 
and 66.7 per cent, of acute cases, give positive results to inoculation 
tests. Miss Clough says that with blood cultures positive results are 
more often obtained of the existence of a bacillemia in tuberculosis, 
and she suggests this method as an aid in differential diagnosis of acute 
miliary tuberculosis from non-tuberculous infections. 

It was necessary to explain the presence in the blood of many cases 
of phthisis of bacilli, which are but rarely pathogenic to animals. It 
was suggested that while inoculating the animals with the blood, anti- 
bodies are also inoculated, or that the germs circulating in the blood 
lose their virulence owing to the bactericidal action of the blood. 

At the present state of our knowledge the following conclusions of 
Klemperer 9 are justified: 

Acid-fast rods are found microscopically in small numbers in the 
blood of a large proportion of consumptives. Animal experimentation 
shows that but few patients have virulent tubercle bacilli in their 

1 The Presence of Tubercle Bacilli in the Blood in Clinical and Experimental Tuber- 
culosis, Hygienic Labor. Bull., No. 57, 1909. 

2 Miinchen. med. Wchnschr., 1912, lix, 1951. 

3 Jour. Am. Med. Assn., 1909, liii, 1915. 

4 Miinchen. med. Wchnschr., 1913, lx, 401. 

5 Am. Jour. Med. Sc, 1915, cl, 377. 6 Am. Rev. Tuberc, 1917, i, 598. 

7 Schmidt's Jahrbucher, 1913, ccxvii, 2056. 

8 Ztschr. f. Hyg., 1914, lxxviii, 253. 

9 Ztschr. f. klin. Med., 1914, lxxx, 88, 



THE RENAL SYSTEM 247 

blood. But it must be mentioned in this connection that in order to 
infect a guinea-pig a certain number of tubercle bacilli are necessary, 
having a certain virulence, perhaps greater virulence than the bacilli 
that survive the bactericidal action of the blood which the average patient 
possesses. Negative outcome of the inoculation, for this reason, does 
not mean absence of the bacilli from the blood. In this connection it 
is important to mention that Marmorek 1 found that after intravenous 
injections into guinea-pigs the bacilli disappear from the blood after 
one or two days, and recur four to six weeks later. After arterial 
inoculation, they disappear after one to two days and recur five to 
fourteen days later. After subcutaneous inoculation bacilli appear 
for the first time in the blood after thirty to sixty days. Inasmuch as 
the acid-fast rods are found microscopically only in the blood of tuber- 
culous and not of healthy persons, the negative outcome does not 
speak against their being tubercle bacilli. Finally, inasmuch as the 
frequency of the occurrence of the bacilli in the blood is supported by 
clinical and anatomical facts, we are justified in considering these 
acid-fast rods as tubercle bacilli. 

The finding of these bacilli in the blood is of no potential diagnostic 
and prognostic value, while about their immunizing effects we cannot 
speak with any degree of certainty. 

THE RENAL SYSTEM. 

The Kidneys. — There appear to be no changes in the structure and 
functions of the kidneys which can be considered specific and char- 
acteristic of early phthisis, excepting in cases with a very acute onset, 
with high fever, which affects these organs in the same manner as 
hyperthermia due to other causes, or in cases in which the kidneys are 
inoculated at the onset together with many other organs, as in acute 
miliary tuberculosis. Recent investigations of the renal function by 
Charles W. Mills 2 and John T. Henderson, and by also Elmer H. Funk, 3 
show that in the incipient stage it is normal, and that it is reduced 
in the advanced stages of the disease only when there is evidence of 
structural damage to the kidney. 

Some writers, notably the French, have described polyuria, phospha- 
turia and albuminuria as very frequent in early and even in latent 
phthisis. Barbier 4 says that albuminuria is often the only sign observed 
for a long time before other symptoms make their appearance; and 
that this albuminuria is often misunderstood by physicians. Albert 
Robin 5 describes pretuberculous polyuria: The quantity of urine in 
the early stage is increased; in the second stage normal; and in the 
third stage diminished, although some patients have polyuria through- 

1 Berl. klin. Wchnschr., 1907, xliv, 18. 

2 Am. Rev. Tuberc, 1917, i, 574. 3 Ibid., 1918, i, 145. 

4 Brouardel and Gilbert's Traite de Medecine, Paris, 1910, xxix, 423. 

5 Traitement de la tuberculose, p. 498. 



248 CARDIOVASCULAR AND RENAL SYSTEMS 

out the course of the disease. The oliguria of the advanced stage is 
closely related to the fever, sweats, and eventual diarrhea. Robin 
maintains that the polyuria of early phthisis is simple showing no 
abnormal constituents or, at most, there may be phosphaturia, when, 
at times, it may be severe enough to cause irritation of the kidney 
substance, congestion, and, finally, albuminuria. 

These changes have, however, not been met with sufficient constancy 
to place them in the category of pathognomonic or specific symptoms 
of early tuberculosis. Among 100 cases of early tuberculosis that I have 
especially investigated for the purpose of testing this point, I found 
albuminuria in only 9 cases, and casts in only 3. 

Albuminuria in Advanced Cases. — In the advanced stages albumin- 
uria is very frequent. Montgomery found albumin present in about 
one-third. of cases of phthisis. In the majority of cases the amount 
was only a trace and when found in larger amounts it was always asso- 
ciated with casts and blood or pus. By using delicate methods Mills 
and Henderson found traces of albumin, with or without hyaline casts 
in 40 per cent, of sanatorium patients. It appears that cases with 
intestinal ulcers have larger amounts of albumin than others. From 
his studies he arrives at the conclusion that a large number of casts in 
the urine of consumptives are indicative of an unfavorable prognosis, 
and the reverse. 

As to the causes of the albuminuria we are not clear. Some look upon 
it as caused by the irritation of the tuberculous toxins, which are elim- 
inated with the urine, on the renal parenchyma, while others see in it 
the effects of the chronic fever, or actual tuberculosis of the kidneys. 
In an exhaustive study of the problem, N. Leon-Kindberg 1 arrives at 
the conclusion that the so-called " tuberculotoxins" cause no lesions 
in the kidneys. The presence of isolated tubercles in the kidneys 
explains perhaps some cases of bacteriuria. 

It must be mentioned that mixed infection, such as is seen in pul- 
monary cavities containing, in addition to tubercle bacilli, also pyogenic 
microorganisms, is usually the cause of albuminuria in the advanced 
stages of phthisis where there is no concomitant renal tuberculosis. 

Nephritis in the Course of Phthisis. — Symptoms of acute nephritis 
are very rarely met with during the course of phthisis ; but the chronic 
degenerative forms, parenchymatous and interstitial, have, however, 
been found in variable proportions. Bamberger found nephritis to- 
gether with phthisis to the extent of 15 per cent.; Potain states that 
one-fifth of all consumptives have nephritis; and others have found 
even higher percentages. Senator was inclined to the opinion that 
tuberculosis is an important etiological factor in chronic parenchy- 
matous nephritis. But it appears that clinical symptoms of nephritis 
are usually altogether absent, even when albumin and casts are found 
in the urine, and cardiac hypertrophy is exceedingly rare. 

1 fitudes sur le rein des tuberculeux, Paris, 1913. 



THE RENAL SYSTEM 249 

Most of these views are based on the presence of albumin in the 
urine, and Montgomery 1 has shown that in pulmonary tuberculosis 
albumin and casts are not often associated with evidences of nephritis. 
/// phthisis, albuminuria is not necessarily a manifestation of nephritis, 
or even of renal tuberculous lesions, but in many cases, especially in 
fibroid phthisis and emphysema, it is due to cardiac dilatation, to 
intestinal and hepatic disturbances, etc., which are so frequent in 
advanced phthisis. Albuminuria may also be the sole indication of a 
tuberculous lesion in a kidney which manifests itself by no other 
symptom during life. Thus, in a painstaking study of 106 pairs of 
kidneys taken from consumptives, made by J. Walsh, 2 53.9 per cent, 
were found to contain tubercles. He also found that among these 106 
pairs of kidneys only 10 showed chronic interstitial nephritis, while in 
44 kidneys from patients suffering from other chronic diseases, there 
were 23 with this form of nephritis, which clearly indicates that tuber- 
culosis of the lungs is antagonistic to the ordinary chronic general 
interstitial nephritis, just as it appears antagonistic to general sclerosis 
of other organs. 

The Amyloid Kidney. — In the far-advanced stages of phthisis with 
large suppurating cavities in the lungs, we often encounter amyloid 
degeneration of the kidneys, as in cachexia due to other causes. It 
is usually found associated with amyloid changes in other organs, 
notably the liver, spleen, and intestines. But even this is not as fre- 
quent as would be expected. White found 9.2 per cent.; Walsh 6.6 
per cent., and he never found it exclusively in the kidneys; Blum in 
only 6 per cent., but he points out that 79.2 per cent, of all amyloids 
were caused by tuberculosis, of which 54.4 per cent, is pulmonary 
phthisis. 

Its symptomatology is that of amyloid disease of the liver and intes- 
tines, and because it is always associated with other changes in the 
kidneys, such as chronic parenchymatous nephritis, the resulting 
symptoms are always complex. Albumin is usually present in the urine. 
I find it safe to conclude, when the liver is enlarged and there is pro- 
fuse diarrhea, that there is no doubt that the kidneys are amyloid. 
But when there is no diarrhea, there is polyuria of low specific gravity, 
casts, and but little albumin. 

Terminal Edema. — Edema fs present in a large proportion of cases 
of advanced phthisis ; the ankles and knees especially are thus affected 
during the terminal stages, but it does not always depend on the con- 
dition of the kidneys. Montgomery found no relation between edema 
and the occurrence of albumin and casts in the urine, and suggests 
that the edema found in tuberculosis does not depend primarily on 
nephritis. General anasarca is often seen in far-advanced cases toward 
the end, and this may be a manifestation of the state of the kidneys, 

1 Fourth Annual Report Henry Phipps Institute, 190S, p. 120. 

2 Tr. Sixth Intern. Congr. Tuberc, 1908, i, 347. 



250 



CARDIOVASCULAR AND RENAL SYSTEMS 



but when we bear in mind that in these cases we also have cardiac 
dilatation, it is clear that the pathogenesis is often complex. 

The edema may be considered an ill omen, and I have not seen a 
consumptive with edematous ankles and knees survive, or even 
improve. It may be unilateral, sometimes one-half of the body is 
swollen and pitting, corresponding to the side on which the patient 
lies. At times we see it only in one upper extremity, due to pressure 
on the veins coming from the arm by tuberculous glands, or when they 
are implicated in the adhesive pleurisy of that side, and more com- 
monly by thrombosis of the innominate, subclavian, or other veins. 
Phlebitis or thrombosis of the femoral, popliteal, and crural veins is 
even more frequent (see Chapter XXIX). 

Uremia. — Symptoms of uremia are not often met with in phthisis, 
but not so rarely as some authors would lead us to believe. In the 
advanced stages we meet at times with typical uremia, which is often 
mistaken for meningeal infection. I have seen several cases of convul- 
sions due to this cause. In severe dyspnea without fever, arising 
suddenly, uremia is to be thought of in cases with albumin and casts 
in the urine. Often the diarrhea observed in these cases is distinctly 
of uremic origin, and at times we meet with pulmonary edema. These 
conditions are usually very difficult of recognition and differentiation. 



CHAPTER XIII. 
NERVOUS SYMPTOMS OF PHTHISIS. 

As an exquisitely chronic disease, phthisis is accompanied by many 
morbid manifestations of the nervous system; in fact, nearly every 
symptom of the disease is often influenced by the effects of the tuber- 
culous toxins on the nervous system. The neurotic phenomena may 
make their appearance immediately at the outset, in some they pre- 
cede the actual onset of phthisis, while most confirmed consumptives 
have a psychology peculiarly their own, and show symptoms of 
nervous aberration which cannot escape the vigilance of the observant 
physician. 

Neurasthenia and Psychasthenia. — The onset of phthisis is often 
accompanied by symptoms simulating that syndrome which is known 
under the vague term of neurasthenia; indeed, many patients have 
been treated for neurasthenia for months before the true nature of 
their affection was recognized. These symptoms have been described 
by many authors and deserve careful consideration. 

A large proportion of incipient and confirmed consumptives complain 
of vertigo, headache, pains along the spine, irritability of temper, 
insomnia, not necessarily due to nightsweats, and fleeting pains of the 
chest which, at times, cannot be attributed to circumscribed pleurisy; 
frequent attacks of tachycardia, irrespective of the temperature, and 
cardiac palpitation, are not rare. There is also the characteristic 
languor and persistent weariness, which is not relieved by sleep; on 
the contrary, many state that they feel more weary and tired in the 
morning, on getting out of bed, and that this tired feeling wears off 
in the afternoon or evening, all of which is suggestive of neurasthenia 
and psychasthenia. Considering these symptoms there is little 
wonder that many patients are treated for " nervousness" until an 
attack of dry or moist pleurisy, or of hemoptysis, or a careful examina- 
tion of the chest, reveals the true state of affairs. Papillon 1 goes so 
far as to say that he suspects every victim of neurasthenia to be a 
subject of latent tuberculosis, and G. D. Head 2 considers a considerable 
proportion of neurasthenics as harboring a tuberculous infection which 
is so concealed that it escapes detection by the usual clinical methods. 
Considering that neurasthenia is quite often the result of toxic causes, 
it is clear that tuberculous toxemia may be a cause of these symptoms 
in many cases. If the chests of all patients treated for neurasthenia 

!Arch. de Scien. Med., 1900,- v, 19. 
2 Jour. Am. Med. Assn., 1914, lxiii, 996.. 



252 



NERVOUS SYMPTOMS OF PHTHISIS 



were carefully examined, a large proportion of phthisis which is now 
only recognized in the advanced stages would he identified at earlier 
stages. 

Reflex Nervous Phenomena. — Aberrations of the sympathetic or 
autonomic nervous system are not rare in phthisis. Among these may 
be mentioned the unilateral flushes of the face and occasionally of one 
ear, combined with a feeling of warmth, sweating, etc. In some cases 
it has been observed that the cutaneous temperature is higher on one 
side of the chest. These unilateral symptoms are usually found on the 
side corresponding to the affected hemithorax and, in bilateral lesions, 
to the side in which the recent, or more active, lesion is located. In 
some patients with extensive excavations in the lung, the nostril cor- 
responding to the affected side is widely dilated. Dermographism 
is very frequent. These disturbances in the autonomic system have 
recently been studied carefully by Meyer Solis-Cohen. 

An important symptom of phthisis is dilatation of the pupils, to which 
Rogue, 1 Destree, 2 and also T. F. Harrington 3 drew attention. Har- 
rington described the widely dilated pupils as "not a paralyzed pupil, 
but rather one which seems to be in a more or less constant state of 
dilatation, due to some irritation along the track of the nerve fibers in 
the celiospinal region," and says that they may be found in cases before 
the evidences of active disease can be discovered. But dilatation of 
but one pupil is more frequent, some authors saying that it occurs in 
more than 50 per cent, of cases; that it is an early symptom and may 
be found before other symptoms and signs make their appearance. 
More recently Meyer Solis-Cohen, Emil Sergent, 4 and H. Saint- 
Aude 5 have given this symptom attention. Sergent has shown that this 
sign is not peculiar to syphilis, but that it is very frequently encoun- 
tered in pleuropulmonary tuberculous lesions and especially in chronic 
phthisis. He distinguishes several varieties. The inequality may be 
an isolated phenomenon, and the abnormal pupil is on the same side 
as the affected lung. It may also be a part of an oculopupillary syn- 
drome, myosis being accompanied by diminution of the palpebral 
fissure and retraction of the eye-ball on the affected side. In some 
cases the inequality of the pupils not only forms part of the oculo- 
pupillary syndrome, but is also accompanied by vasomotor symptoms 
in the cheek and ear on the same side. Instead of myosis of the pupil 
on the side corresponding to the affected lung, there is mydriasis with 
vasomotor symptoms but without the oculopupillary syndrome. It 
is mainly seen in cases of phthisis in wdiich the apical pleura is involved 
in the process, and in apical pleurisy. In most cases of this type there 
is also found some swelling of the supraclavicular glands (see p. 428). 



1 Gaz. med. de Paris, 1869. 

2 Jour, de med. et de pharm., 1894, 241. 

3 Boston Med. and Surg. Jour., 1899, cli, 575. 

4 Ann. de Med., 1917, iv, 140; Progress Medicale, 1912, xxviii. 234. 
s These de Paris, 1917-18, No. 63. 



PAINS 253 

It is due to irritation of the cervical sympathetic by the inflammatory 
process in the lung apex and pleura. With the improvement in the 
disease the difference in the pupils may disappear, but I have seen it 
persist after the patient recovered. At times, one pupil is unduly 
contracted. 

Muralt 1 pointed out that these unilateral nervous phenomena may 
be obseived within certain limits experimentally after the induction 
of therapeutic pneumothorax. He found that with the increase in the 
intrapleural pressure, the pupil dilates and the cheek flushes on the 
affected side, and in some cases there are typical attacks of migraine, 
while with the decrease in the pressure the phenomena disappear. 

Pains. — While a large proportion of tuberculous patients pass 
through the disease painlessly, there are many who suffer from pains 
and aches of various degrees of severity. The pains may be in any 
part of the body, but the most characteristic are those of the chest 
and upper extremity. Kuthy found that among 650 patients, 60 per 
cent, had pains in the chest, and of these it was localized in 85 per cent, 
in the affected, or more affected, side. 

Many of my patients have received the first intimation of trouble 
with their lungs through pains which were usually felt in the infra- 
clavicular space above the second rib, and more often in the supra- 
spinous fossa, between the shoulder-blades, or under them. It is 
usually of a dull character, uninfluenced by motion, breathing or 
coughing, worse during the night. The skin over the affected area 
is only rarely tender, but deep pressure almost invariably aggravates 
it; tapping this region may bring on a coughing spell. Hyperesthesia 
of the spine between the shoulder-blades is quite common. 

In more advanced phthisis pains in the shoulder may be actually 
agonizing, worse during the night, depriving the patient of his sleep 
and resisting all therapeutic efforts at relief. When occurring in the 
incipient stage they are not so acutely felt, but may extend all along 
the arm and forearm down to the finger tips. Minor exposures to the 
vicissitudes of the weather may bring about pains, and the patient then 
believes that he is affected with rheumatism. In fact, many cases 
of "rheumatism" of the shoulder turn out to be phthisis. Diaphrag- 
matic pains are frequent. They are described by the patients as stab- 
bing in character, or as if there was a wound in that region, and are 
usually due to pleural adhesions and may be aggravated by deep 
breathing, coughing and sneezing. 

Hyperesthesia is very rare in phthisis unless there is complicating 
pleurisy. The pains are usually elicited by pressure on the regional 
muscles over the affected parts of the lungs. When the apex is affected, 
the sternocleidomastoidei and the trapezii may be painful; when the 
lesion is more extensive the scaleni, pectorales, and intercostals, and 
when there is a lesion at the base, the lumbar muscles may be painful 

i Mediz. Klin., 1913, ix, 1814 and 1901. 



254 NERVOUS SYMPTOMS OF PHTHISIS 

on pressure. In pleurisy there are hyperesthesia and hyperalgesia (see 
p. 423). These pains are not due to cough because they are unilateral. 
They are accompanied by spasmodic contractions of the regional 
muscles, caused by reflex irritation of the supplying nerves. 

These pains have been studied very carefully by Henry Head, 1 
James Mackenzie, 2 and more recently in this country by Lovell Langs- 
troth. 3 Head found that these pains were either local or referred, and 
when due to pleurisy they coincided precisely with the situation of 
the pleural area involved, and were accompanied by deep tenderness, 
but not by superficial hyperalgesia. In cases of phthisis marked by 
successive acute or subacute attacks, involving previously healthy 
parts of the lung, refened pains were mostly found. He attributed 
them to the fact that the end-organs of the sensory nerves in the por- 
tion of the lung invaded remained intact, and capable of conveying 
impressions when irritated. These nerve endings were destroyed after 
the disease advanced, causing necrosis, and were no more capable of 
causing referred pain. Superficial tenderness is particularly liable to 
spread along the paths of the nerves and Head believed it due to the 
cachexia and pyrexia characteristic of each acute exacerbation of the 
disease. Within certain limits, he was able to determine the lung area 
involved by the cutaneous hyperalgesia. A review of the various forms 
of pains in phthisis is given by F. Jessen 4 and J. L. Pomeroy 5 in special 
monographs. It appears, however, that Langstroth's conclusion to 
the effect that this hyperalgesia is practically of no importance in 
diagnosis, or in localizing pulmonary lesions, is correct. But in the 
diagnosis of pleurisy, especially of the diaphragmatic portion of the 
pleura, a study of the referred pains is of universal diagnostic impor- 
tance (see p. 424). 

It appears that the tenderness found in active phthisis is the result 
of the rigid contraction of the muscles — an attempt on the part of the 
muscles to protect the diseased viscera beneath them. It is replaced 
by muscular atrophy in the later stages of phthisis. 

The origin of the various pains in phthisis is not always clear. It 
has been shown by J. Mackenzie that the lung is insensitive to stimu- 
lation when healthy or diseased, as is evident from the fact that when 
an exploring needle penetrates the lung the patient feels no pain. In 
fact, no form of stimulation of lung tissue seems to be capable of 
producing sensation, directly or reflexly. It is for this reason that 
necrosis of lung tissue, as it occurs in gangrene, abscess, or tuberculous 
cavity formation, is usually painless. 

The suggestiDn that the pains in phthisis, as well as in pleurisy 
and pneumonia, are due to pleural involvement does not hold either, 

1 Brain, 1896, xix, 153. 

2 Symptoms and their Interpretation, London, 1909. 

3 Arch. Int. Med., 1915, xvi, 149. 

4 Lungenschwindsucht und Nervensystem, Jena, 1905. 
^Interstate Med. Jour., 1912, xix, 829. 



PSYCHIC TRAITS 255 

because the pleura is insensitive. Mackenzie states that he repeatedly 
explored the pleural cavity for any evidences of sensation and could 
employ no form of stimulation capable of producing pain. When 
inducing therapeutic pneumothorax I have repeatedly observed that 
entering the parietal pleura with the needle produced no pain, nor 
does scratching the visceral pleura with the point of the needle produce 
any sensation. Mackenzie is therefore inclined to attribute pains 
of the kind mentioned above to contraction of the overlying muscles. 
This is the reason why no hyperesthesia of the skin is met with in 
phthisis, but pressuie pain is frequent. It is due to a visceromotor 
reflex and occurs along the distribution of the sensory nerves which 
are stimulated by the lesion. The above-mentioned pain in the shoulder 
can be explained by irritation in diaphragmatic pleurisy of the phrenic 
nerve which conducts the stimulus to the skin of the shoulder. Both 
the phrenic and fourth cervical nerves leave the spinal cord at the 
same place, and the former nerve conducts afferent fibers, as well as 
efferent (motor), and it is in all probability by the former that the 
stimulus is conveyed to the center of the fourth cervical nerve in the 
cord. Pottenger also attributes these shoulder pains to an inflammation 
of the nerve resulting from the reflex segmental stimulation — a true 
neuritis. On the other hand, a recent investigation by Capps 1 seems 
to indicate that irritation of the central part of the diaphragmatic 
pleura gives referred pain in the neck; and irritation of other parts 
also gives rise to true referred pains, set up by impulses carried to the 
third and fourth cervical segments by the phrenic nerve, and thence 
to the areas of these segments. This point is discussed in detail in 
Chapter XXVI. 

During the last few days of life the reflexes are usually abolished 
in the phthisical and they are relieved from all pains; in fact, at times 
we find them very hopeful because they feel no more pains. 

Psychic Traits. — Psychoses met with among tuberculous patients 
may be considered in the main as coincidences, because so many people 
suffer from phthisis, and, inasmuch as this disease is no bar against 
mental alienation, it is but natural that some should become insane 
from any of the causes of this aberration. It is a fact than an enormous 
proportion of insane die from phthisis — Clouston 2 states that two- 
thirds of deaths among idiots result from tuberculosis — but this may 
be due to their irrational mode of life, as well as to their confinement 
in institutions. Delirium is also very often seen in the terminal stages 
of phthisis and, when not due to meningeal complication, it does not 
differ from the delirium seen in inanition, exhaustion, or febrile intoxi- 
cation due to other causes. But in addition to these occasional psychic 
disturbances, which might be expected, there have been noted other 
psychic disturbances in phthisical patients, and many authors have 
spoken of a characteristic psychology of the consumptive. 

1 Arch. Int. Med., 1911, viii, 717. 

* Allbutt's System of Medicine, viii, 307, 



256 NERVOUS SYMPTOMS OF PHTHISIS 

These phenomena have been observed also in infants. Combe 1 is 
in agreement with other authors that ths tuberculotoxins act on the 
nervous system of infants, as of older children, and cause a decided 
change of character. The infant loses its gayety; it never smiles, but 
cries without cause. It sleeps badly, awaking often, but is difficult to 
arouse in the morning. This change in character is mostly observed in 
children with tuberculous meningitis, but is also seen in those suffering 
from other forms of tuberculosis. 

Many tuberculous patients show a remarkable change in their mental 
traits and character, a disturbance in their emotional life and a striking 
divergence from their previous customs, habits, affections, and tastes. In 
some, this change precedes the evident onset of the disease, in many 
it appears synchronously with the symptoms of active disease ; it may 
ameliorate with each improvement, and aggravate with each acute 
exacerbation. 

This change in character manifests itself in various other ways: 
Liberal persons may become stingy and misanthropic, brave ones 
become cowardly, etc. Engel 2 points out that the original, innate 
temperament or character of the individual becomes strikingly pro- 
nounced in the chronic consumptive: The pessimist suffers from 
marked despondency; the optimist becomes unreasonably hopeful of 
the ultimate outcome, etc. These phenomena may be explained by 
the discordance between the subjective feelings of the patient who is 
not as disabled as the objective findings of the physician would lead 
to expect. The mental make-up of the patient depends greatly on 
his physical condition which, in tuberculosis, is subject to great oscil- 
lations; aggravations and improvements coming and going quite 
unexpectedly. The mental traits per se do not change, but such traits 
as were characteristic during youth but, as a result of education, 
training, and the vicissitudes of life, have been suppressed, reappear 
boldly, unhindered by conventionalities. 

A psychic trait of the consumptive which has been noted by most 
writers is selfishness. He becomes egotistical and egocentric. He is 
interested in the welfare of but one person — himself — to the exclusion 
of all who have depended on him before. He w^ll eat costly food 
while his children starve; he will make unreasonable demands on his 
relatives and friends and show no gratitude. In sanatoriums this has 
been the most important problem with which the officers have to cope, 
and the failure of many superintendents is due to their lack of appre- 
ciation of this trait of the consumptive. As Saxe 3 states, the ascendence 
of selfishness plays the most important role in the molding of the 
mental traits of the tuberculous. In some patients these factors are 
so pronounced that they completely reveal the concealed elements of 
their characters. 

1 Le Nourjsson, 1916, iv, 73. 

? Mimchen. med. Wchnschr., 1902, xlix, 1383. 

3 New York Med. Jour., 1903, lxxviii, 211 and 263. 



EUPHORIA AND EUTHANASIA 257 

Euphoria and Euthanasia. — Optimism, despite many evidences of 
progressive disease which saps the body, is frequent; only a copious 
hemorrhage, or, more rarely, a spontaneous pneumothorax, will terrify 
the average tuberculous patient. Otherwise, all the symptoms amount 
to little or nothing. An increase in the cough is due to a "cold;" 
anorexia is caused by bad food, etc. 

Barring the functional neuroses, there are no diseases in which 
suggestion — auto- and heterosuggestion — is so effective in modifying 
the course of the malady or in relieving symptoms. An injection of 
water will induce sleep, relieve pain, cough, etc., and even produce 
an increase in temperature exactly like that of the tuberculin reaction. 
In many European sanatoriums there is a routine measure before 
applying tuberculin for diagnostic purposes, to inject water with a 
view of ascertaining whether the fever is due to psychic effects or to 
the tuberculin. It has been found that 20 per cent, of patients react 
to the injectio vacua. Some physicians have been able to suggest the 
hour of the day when the reaction will appear, as well as any or all 
the symptoms which make up the typical tuberculin reaction. The 
effects of this high susceptibility to suggestion are seen in phthisio- 
therapy; quack doctors and remedies are thriving on consumptives 
more than on any other class of patients, excepting perhaps the 
venereal, in whom the element of secrecy is of importance. 

The proverbial euphoria and euthanasia of the consumptive, which 
have been described in such great detail by many medical authors, and 
which have not escaped the attention of writers of fiction who are alert 
for strong dramatic effects, are other manifestations of the proclivities 
to autosuggestion. Experience has taught that when a patient with 
excessive excavations in the lungs, running high fever, and presenting 
other symptoms and signs of this condition, begins to believe that he 
has improved, that he "feels fine," has no pains, does not cough 
distressingly, we may look for a speedy relief of the unfortunate by 
that greatest of benefactors for these desperate sufferers, death. It 
is often astonishing to behold the sinking man make plans for the 
future, engage in new enterprises, plan long voyages — not for a cure, 
which he believes he has almost attained, but for pleasure — or, as I 
have seen, arranging for his marriage a few days before his death. 

Very often this optimism and euphoria are excellent aids in our 
attempts at curing these patients. It is a well-known fact that there 
is hardly any hope for a despondent consumptive. On the other 
hand, this euphoria is occasionally harmful because it misleads the 
patient and he neglects the instructions of his physician. 

It appears that as a result of the prolonged state of intoxication 
produced by the absorption of the poisons resulting from the metab- 
olism of the tubercle bacilli, as well as of the products of decom- 
position of the affected lung tissue, the consumptive is in about the 
same mental state as those who are under the influence of mild alcoholic 
intoxication. The external appearance^of the consumptive betrays 
17 



258 NERVOUS SYMPTOMS OF PHTHISIS 

his state of intoxication. His bright eyes with dilated pupils, which 
are at times contracted unilaterally, the flushing cheeks, the keen 
intellect which is so often met with among those who before the 
onset of the disease were rather dull in this respect, coupled with a 
flickering intelligence which brightens up suddenly for a few hours, 
but is soon followed by mental depression or fatigue, bear close resem- 
blance to the average person who is under the influence of moderate 
doses of alcohol, or a narcotic drug. 

In tuberculous patients, particularly young talented individuals, it 
is noted that for a few weeks or months, now and then, they display 
enormous intellectual capacity of the creative kind. Especially is 
this to be noted in those who are of the artistic temperament, or who 
have a talent for imaginative writing. They are in a constant state of 
nervous irritability, but despite the fact that it hurts their physical 
condition, they keep on working and produce their best work. This 
spes phthisica has been described by many authors, notably by J. B. 
Huber 1 and A. C. Jacobson 2 in this country. 3 They maintain that 
"the quality of genius may, m some cases at least, be affected by 
tuberculosis," and that the intellectual powers of the genius are 
quickened by reason of the general psychic exitation resulting from the 
action of the tuberculous by-products. "They astonish everybody," 
says Letulle, 4 "with their mental and intellectual activity; their 
memory, their quick judgment, their delicate reasoning powers are of 
incomparable amplitude." 

The long list of great writers and artists given below, to which many 
more may be added, shows that tuberculosis is rather frequent among 
talented individuals, and suggests that it may be enhancing their pro- 
ductivity instead of reducing it as would be expected a priori. 

Insomnia. — Insomnia in the early stages of phthisis may be due 
to restlessness owing to worry because of the diagnosis of a dangerous 
disease, and is often rem:ved by emphatically reassuring the patient. 
Indeed, the characteristic attitude of optimism soon prevails and the 
patient is no more disturbed by insomnia. 

In others insomnia is due to excessive cough, or nightsweats, or 
b3th. In some cases the administration of hypnotic remedies is of 

1 Consumption and Civilization, Philadelphia, 1906. 

2 Interstate Med. Jour., 1914, xxi, 341. 

3 It is interesting to mention some of the notable men and women who were tuber- 
culous. Among them may be mentioned: Rousseau, Milton, Kant, Locke, Hawthorne, 
Keats, Shelley, Emerson, Washington Irving, Chopin, Laennec, Spinoza, Hurrell Froude, 
Sterne, Thoreau, Charlotte Bronte, Ruskin, Robert Pollok, Kingsley, Channing, Michael 
Bruce, Beranger, Thomas Hood, James Ryder Randal, Lanier, Scott, Elizabeth Barrett 
Browning, Bichat, Moliere, Rachel, Calvin, Bastien-Lepage, Robert Louis Stevenson, 
Watteau, Jane Austen, Francis Beaumont, David Gray, Richard Lovelace, Georges 
de Guerin, Voltaire, Amiel, Paganini, von Weber, Nevins, Marie Bashkirtseff, John 
Addington Symonds, George Ripley, Paul Laurence Dunbar, Westcott, Blackmore, 
Joseph Rodman, Drake, Kirke White, Stephen Crane, Adelaide Anne Procter, N. P. 
Willis, Henry Timrod, H. C. Bunner, John Sterling, R. Koch, Maxim Gorky, and many 
others. 

4 Arch. gen. de med., 1900, ii, 258. 



INFLUENCE OF TUBERCULOSIS ON SEXUAL SPHERE 259 

no avail so long as they are given in safe doses. Especially prone to 
insomnia are patients who suffer from paroxysmal attacks of cough, 
each fit waking them and keeping them awake for one-half to two 
hours. In these cases the administration of cod em, heroin, etc., is 
imperative. Profuse nightsweats often act the same way: After 
waking bathed in perspiration, the patient finds it difficult to fall 
asleep again. 

During the advanced stages many patients find it very hard to sleep 
because of the copious secretions in the pulmonary cavities which, 
after a short nap, overflow the bronchi and compel them to rise and 
expel it from the chest. Some with unilateral lesions may be able to 
sleep the greater part of the night in certain positions, and they adapt 
themselves to the conditions. But in others with cavities in both 
lungs, or with sinuses leading from the cavities in different directions, 
the prone posture immediately induces cough. Some have to sleep 
with the face downward if they want to avoid cough, others in the 
semireclining posture, etc. We also meet with cases in which dyspnea 
is the cause of insomnia. While during the early stages of phthisis 
fever may be the cause of insomnia, it is only rarely the case during 
the advanced stages. The average consumptive has adapted his 
organism to the fever and does not mind it very much. Tuberculous 
patients with high fever are often seen sleeping quite soundly as long 
as the cough, nightsweats, and dyspnea do not disturb them. 

In the terminal stage we often observe abnormal somnolence in 
phthisical patients. For days, at times for weeks, the patient lies in a 
semicomatose condition, careless about his person, and only now 
and then wakes to ask for some nourishment. If not due to excessive 
sedative medication, it may be an indication of meningeal complica- 
tion. But I have had cases in which this abnormal somnolence has 
existed for several days or weeks before death, and the autopsy showed 
no meningeal tuberculosis. Some of these patients have periods when 
they are mildly delirious. 

Influence of Tuberculosis on the Sexual Sphere. — The tuberculous 
toxemia has a profound influence on the sexual organs and their 
functions. In women, menstrual disturbances are not uncommon 
during the course of the disease, and quite often these disturbances 
are noted before the onset of evident symptoms of the disease. In 
young girls the appearance of menstruation may stay the progress of 
the disease, as I have seen in several cases. Probably for this reason 
ancient clinicians thought that amenorrhea was a cause of phthisis. 
Now we know it to be an effect of the disease. Amenorrhea is very 
frequent during the course of phthisis, and other menstrual disturb- 
ances, dysmenorrhea, menorrhagia, metrorrhagia, etc., may be ob- 
served in many cases. But I know a large number of tuberculous 
women in whom the menstrual function remained practically normal 
throughout the course of the disease. 

During the menstrual days, and at times a few days before the 



260 NERVOUS SYMPTOMS OF PHTHISIS 

appearance of the flow, there is often observed an aggravation in the 
pulmonary condition. The fever may rise, the cough increases in 
intensity, rales increase in number and extent, or reappear in places 
where they were noted before but had disappeared and new areas of 
lung tissue are often invaded during this period. Hemoptysis is quite 
frequent during this period and in rare cases it may even replace 
menstruation. Premenstrual fever is occasionally noted, as was already 
stated. 

Conception is possible at any stage of the disease, and the pregnancy 
may, and often does, pass through almost normally, the child being of 
average weight but of low vitality. Reibmeyr believes that tuber- 
culous women are more prolific than healthy women — Nature attempts 
to compensate in quantity for inferior quality. Abortion and mis- 
carriage are more apt to occur among them than in healthy women. 
It appears that during pregnancy the tuberculous process is, as a rule, 
in abeyance, and the patient may even improve. Writers of former 
generations, like Cullen, recommended marriage to tuberculous girls 
for this reason. Dr. E. Warren 1 in a prize essay published in 1857 
said: " Pregnancy, coition, etc., are particularly desired by women 
affected with phthisis, which constitutes a pointing of Nature toward 
a remedy for the evils by which the system has been invaded." He 
quotes the opinions of authorities like Hippocrates, Sydenham, 
Montgomery, Parr, Rokitansky, Clark, and many others, who held the 
same views on the salutary effects of marriage and pregnancy on 
tuberculosis. Some modern writers hold similar views. In a paper 
published in 1897 Charles W. Townsend, 2 speaking of cases observed 
in the Boston Lying-in Hospital, says that "during pregnancy the 
patient often seems better and the disease appears in abeyance," 
and that "Nature seems to put forth a supreme effort to suppress 
the disease during pregnancy and to make the labor easy and short, 
but after the child is born the disease advances at a rapid rate." 

There is no question that during pregnancy the more annoying 
symptoms are in abeyance in many cases. In fact, it is rare to see a 
woman becoming sick with progressive disease during the period of 
pregnancy. In a rather extensive experience, having had under my 
care numerous pregnant women with tuberculous lung lesions in 
various stages of the disease, I have never seen one die with the fetus 
in her uterus. But after the child is born the disease flares up cmd often 
begins to progress with frightful rapidity. A considerable proportion of 
tuberculous women date back the beginning of the disease to childbirth. 
Labor seems to stimulate the process in the lungs and favors the 
development of progressive disease. Women in the incipient stage of 
phthisis, and those in whom the disease was arrested or even cured, 
are apt to suffer an extension of the process, or a relapse or recurrence 
of active phthisis after pregnancy and childbirth. The same phenom- 

1 Am. Jour. Med. Sc, 1857, xxxiv, 87. 

2 Boston Med. and Surg. Jour., 1897, lxxxviii, 391. 






SEXUAL IRRITABILITY 261 

enon has been observed in cattle. In cows tuberculosis is reactivated 
after pregnancy and labor. 

Sexual Irritability. — The popular views entertained by the laity 
and the profession to the effect that consumptives have excessive 
sexual potency and demands are apparently well founded. During 
the incipient stage of the disease there is often noted an increased 
sexual irritability, and this is apparently the reason why some believe 
that phthisis is at times due to excessive venery. Lettule asserts that 
sexual excesses are common at the commencement of the disease, and 
are checked only when the limit of exhaustion is attained. W. H. 
Peters 1 observed a tendency to abnormal sexual excitement so frequent 
among consumptives as to require the careful attention of the physician. 
He also says that "every physician has been impressed by the almost 
disgusting, and sometimes revolting persistence of the sexual instinct 
in consumptives, even late in the disease." 

It is noteworthy that in the advanced stages of the disease, when 
the body is extremely emaciated, the muscles atrophied and the 
vital forces apparently at their lowest, sexual potency may be retained. 
Even shortly before his death a consumptive may impregnate his wife, 
and a woman who has lost half her normal weight, and is subject to 
frequent hemorrhages, runs a febrile temperature, sweats and coughs 
distressingly, is, at times, seen in a pregnant state. Peters quotes 
H. L. Barnes, superintendent of the Rhode Island Sanatorium, about 
a patient who died from a hemorrhage coming during the sexual act 
which took place while on a visit from the sanatorium to his wife. I 
have seen several somewhat similar cases. In hospitals for advanced 
consumptives the patients must be watched in this regard, especially 
when the male division is not completely separated from the female 
division. Sexual excesses, according to Gimbert, 2 often hasten the 
fatal outcome of the disease. 

Other writers deny altogether that consumptives are more sensuous 
than others. Karl von Ruck, 3 in a review of the subject, arrives at 
the conclusion that "phthisis is not a cause of sexual excesses, there 
being no difference between tuberculous and non-tuberculous subjects; 
that in the advancing disease the sexual functions decline the same 
as they do in other wasting diseases." But the bulk of the evidence 
appears to favor the view that excesses are more common among 
consumptives than among others. 

These sexual excesses have been attributed to the tuberculous 
toxemia, but others have denied this explanation. It has been stated 
that the lazy, indolent life, the lack of muscular exercise, and the 
excessive consumption of nitrogenous food during the treatment are 
more responsible for the sexual proclivities than the tuberculous 
toxemia. It has also been stated that in sanatoriums the association 

1 Jour. Am. Med. Assn., 1908, 1, 938. 

2 Rev. de la Tuberc, 1907, iv, 1. 

3 Am. Jour. Dermatol., 1907, xi, 284. 



262 



NERVOUS SYMPTOMS OF PHTHISIS 



of the sexes favors tendencies in this direction. In many the despon- 
dency engendered by the knowledge of suffering from an incurable 
disease urges the patient to take in as much of life and its pleasures 
as possible before it is too late. 

There are other chronic . diseases in which the patients are idle, 
eat well and may be despondent, yet they do not indulge in sexual 
excesses to the same extent as the tuberculous, which would be in 
line with the suggestion that the tuberculous toxemia is effective in the 
direction of causing sexual irritability. Turban found that in artificial 
tuberculin poisoning, i. e., when tuberculin is administered for thera- 
peutic purposes, sexual irritability is increased, and in some cases he 
had to discard specific treatment for this reason. "Every physician 
with a large experience with tuberculous patients," says Muralt, 
"knows of cases in which recovery from the disease brought about 
normal functions in this regard." 

Weygandt 1 made a collective investigation of this problem among 
physicians in German sanatoriums in which incipient cases are ad- 
mitted. Many of the answers were to the effect that they had not 
observed any special increase in the sexual desires of their patients; 
three directors of sanatoriums, Ivohler, Krause, and Marquard, sent 
the interesting information that the patients had accused the doctors 
of secretly putting aphrodisiac or anaphrodisiac drugs into the milk 
or other food. It appears that in many German sanatoriums such 
superstitions prevail, thus indicating that the patients themselves are 
aware of the increased sexual irritability. 



Med. Klin., 1912, viii, 91 and 131 



CHAPTER XIV. 
INSPECTION AND PALPATION. 

The Stigmata of Phthisis. — After the history and symptomatology 
of the patient have been carefully inquired into, the physical examina- 
tion should begin with inspection of the physical make-up of the 
individual. In phthisis not only the chest should be carefully examined 
but also the head, the face, the neck, the abdomen and the extremities. 
The stigmata of this disease are often scattered over various parts of 
the body, and the experienced eye may, at times, find outside of the 
region of the chest certain signs which are highly suggestive of phthisis. 
In some borderland cases these stigmata may be of great assistance 
in formulating an opinion on the diagnosis and prognosis. 

Complexion. — Hippocrates described the habitus phthisicus — the 
"form of the body peculiarly subject to phthisical complaints" — as 
characterized by a smooth, whitish skin, blue eyes, blond or reddish 
hair, and a phlegmatic temperament. Following this ancient clinician, 
many modern writers on this subject have stated that the external 
appearance of certain persons betrays a strong predisposition to this 
disease. 

Hippocrates' notion that blond-haired and blue-eyed persons are 
more prone to phthisis has survived to this very day, and Beddoe, 
Landouzy, Delpeuch, Piery, Woodruff, and many others hold the 
same view. Exact information, however, does not sustain this opinion 
that fair-complexioned people are more prone to tuberculosis. In 
countries with predominant blond populations, like Scandinavia, 
England, Northern Germany, etc., the consumptives are generally 
blonds; while in Italy, Spain, Greece, etc., where the dominant racial 
elements are brunettes, the consumptives are of the same complexion, 
as can be seen on visiting the sanatoriums in these countries. In 
China and Japan there are no blonds, yet tuberculosis is not lacking. 
Evidently infection, the length of time a people has been exposed to 
the tubercle bacilli and, above all, social and economic conditions are 
of greater importance in determining the rates of morbidity and mor- 
tality than race or color. 

Facies. — The confirmed consumptive presents a chaiacteristic, in 
fact, an unmistakable appearance, which betrays his disease not only 
to the experienced physician, but also to the laity, and he can often 
be picked out from a group of healthy people with comparative ease 
and certainty. The emaciated body, the pallor of the face with the 
hectic flush on the cheeks, the round shoulders, and the bodily decrepi- 
tude, may be seen in other wasting diseases; but the facies of the 



264 INSPECTION AND PALPATION 

consumptive, while possessing all these traits, has other characteristic 
stigmata. In very few other diseases is there to be seen such a typical 
facial expression as in the consumptive. 

The facial muscles are wasted, the cheeks sunken, and the malar 
bones protrude; the lips are pale or livid, often contracted, as if 
smiling or grinning; the hectic flush, which may be unilateral; the 
thin neck appears longer than normal, the sternomastoids are accen- 
tuated like two tense bands on both sides; the head is bent forwaid 
between the two round shoulders, and the spine is bent. Because of 
the wasting, the ears appear larger; one may be redder than the other. 

But the most pathognomonic parts of the cast of countenance of 
the consumptive are his eyes. They are deeply set in the sockets, 
which are larger than normal because of the wasting of the orbicularis 
palpebrarum. We also meet with a widening of the palpebral aperture, 
and a slight protrusion of the eyeball on the affected side as a result 
of irritation of the sympathetic. A narrow palpebral aperture with 
a somewhat deeply set eyeball is a symptom of prolonged irritation 
of the nerve paths, and is met with in cases with adherent apical 
pleura, as was shown by Ivuthy. To the same cause has been attrib- 
uted unilateral dilatation, or more rarely, contraction of the pupil 
which may precede the evident onset of active disease. 

The appearance of the eye as a whole is pathognomonic and can 
be more easily recognized than described. It has a characteristic 
brilliancy which has been described as transparent, lustrous, bright, 
dimly brilliant; it differs from the brilliancy of the eyes in other fevers 
in the fact that it appears gloomy, dismal, or haunted — its glance can 
always be felt. Some have attempted to explain these characteristics 
as due to the widely dilated pupils, while the pearly-white sclerotics 
are said to be an expression of vasomotor succulence of the bulbar 
conjunctiva resulting from pressure on the cervical sympathetics and 
are to be seen mostly in cases of adherent apical pleurisy. 

This facies has been recognized by the laity, and the folk-lore of 
Europe abounds in sayings about the facial expression of the consump- 
tive. Writers of fiction and painters have also considered it "inter- 
esting," and make great use of it in their productions. Many of the 
classical and modern painters have depicted this cast of countenance 
showing the false euphoria of the smiling, tranquilly bright, yet 
melancholy eyes of the consumptive, which are perhaps best seen in 
Leonardo da Vinci's La Gioconda — a picture of a phthisical face 
superior to any description that can be given of it. 

I have seen these facies in some patients with latent, or quiescent, 
tuberculosis in whom physical exploration of the chest showed but 
indefinite signs of a lesion. It appears to be especially marked in 
persons of phthisical stock; in other words, those who were infected 
during childhood, but have more or less recovered. 

The Skin. — Other stigmata of phthisis, which may be noted in the 
early stages of the disease, should be mentioned. On the forehead and 



THE STIGMATA OF PHTHISIS 265 

upper parts of the cheeks we may see chloasma phthisicorum, and, in 
those who sweat profusely, pityriasis versicolor and tabescentium on 
the anterior and posterior aspects of the chest. In those who suffer 
from dyspnea, we may find clubbed fingers, or deformities of the hands, 
wrists, spine and ankles, which are the results of pulmonary osteo- 
arthropathy. On the neck, spasm or atrophy of the muscles, which 
will soon be described, may give us a clue that a careful examination 
of the chest is indicated. 

Enlarged Glands. — Visibly enlarged glands are quire rare in adults, 
though I have seen cases in which they went on to suppuration. But 
palpable glands on the neck are very frequent — in at least 50 per 
cent, of my cases. In children, enlarged glands are very frequent, 
but they are not always an indication of tuberculosis. If enlarged 
cervical glands were pathognomonic of tuberculosis in children, we 
should find very few who live in poverty free from this disease (see 
Chapter XXIV). Of greater importance from the diagnostic stand- 
point is enlargement of the supraclavicular glands, especially when 
found unilaterally. It speaks for tuberculosis of the costal pleura. 

We also very often find enlargement of the thyroid gland in tuber- 
culous subjects, at times in the incipient stage, and mild grades of 
exophthalmus are not uncommon. The reciprocal relation between 
hyperthyroidism and tuberculosis is a mooted question. 

Enlarged Veins on the Chest. — Enlarged veins are often seen on the 
chest, especially in the infraclavicular region over the first and second 
interspaces, and posteriorly opposite the first thoracic spine, and below 
along the line of insertion of the diaphragm. The upper enlarged veins 
are caused by the interference with the emptying of the internal 
mammary and intercostal veins, because of pressure on the vena azygos 
by swollen thoracic glands, and also by the increased expiratory efforts 
while coughing. They are occasionally seen in healthy persons, espe- 
cially in nursing women, and they may be unilateral in patients suffer- 
ing from chronic bronchitis and pulmonary emphysema, as well as 
with endothoracic tumors. According to Lombardi, 1 the varicosities 
in the neighborhood of the seventh cervical and first thoiacic vertebra? 
may be seen in 80 to 90 per cent., of cases of phthisis, but I see them 
very frequently in persons without any active pulmonary disease. 

It will also be noted in some cases that the nipple is located lower or 
more externally, while in women the mammary gland may be smaller, 
and the nipple may be less pigmented, than on the opposite unaffected 
side. 

The Phthisical Chest. — Hippocrates, Galen, Aretseus and other ancient 
clinicians mentioned the phthisical chest, and modern text-books 
devote considerable space to giving details about its form, shape 
and significance, notwithstanding the fact that many persons with 
"phthisical chests" pass through life unscathed, while many consump- 

1 Gior. internaz. di Scien. med., 1913, xxxv, 751. 



266 INSPECTION AND PALPATION 



tives have at the beginning of the disease excellent chests. There 
was a time when everyone who had a deformed chest, especially of 
the type called flat, was considered tuberculous or, at least, predis- 
posed to the disease. By actual measurement, Woods Hutchinson 1 
found that the chest of the consumptive is altogether unusually 
round, the sternodorsal diameter is comparatively large when com- 
pared with the average healthy person, and he suggests that it is 
due to a persistence of the infantile thorax in the adult. These observa- 
tions have been confirmed by Bessesen, 2 Niles and others. 

The problem whether the phthisical chest is a cause, congenital or 
acquired, of tuberculosis, has also been raised. As will be shown later, 
all evidence tends to show that it is an expression of intrathoracic 
disease, and thus a result of tuberculosis during childhood. 

The Normal Thorax. — Before looking for the pathological chest we 
must have a clear idea as to what constitutes a normal thorax, and it 
should be stated at the outset that a well-formed thorax is an ideal 
which cannot be encountered more often than a perfectly normal 
physique in the individual. I can do no better than quote Pottenger's 3 
description, which is as complete and thorough as can be given : 

"Such a thorax in an adult should be symmetrical on both sides. 
Beginning at the clavicle it should bulge forward, reaching the maxi- 
mum point on a level with the third or fourth rib and then gradually 
flattened out again as. the lower border of the ribs is reached. The 
supraclavicular and infraclavicular spaces should be well filled and 
almost even with the clavicles themselves. The scapulae should stand 
symmetrically; the ribs and intercostal spaces should be well covered 
with subcutaneous tissue and muscles so that the intercostal spaces 
are barely recognizable in the upper two-thirds of the thorax, and 
are only seen distinctly in the lower portion where the musculature is 
thin. There should be a general symmetry in the muscles of the two 
sides, no individual or group of muscles standing out with undue 
prominence unless it be those that are increased in size by greater 
use, such as the deltoides, trapezius, rhomboides and pectorales in 
persons who do heavy work and use one hand more than the other. 
The anterior neck muscles should not stand out unduly, unless the 
patient is emaciated. Neither should the neck and chest muscles 
appear degenerated or atrophied under normal conditions. " 

While such an ideal chest is only rarely seen in healthy persons, it 
is never seen in a consumptive. In the latter, going hand -in-hand 
with the progress of the disease, the form and shape of the thorax 
change, as a result of certain changes in the respiratory muscles, and 
in many cases we find on inspection and palpation conditions which 
are characteristic of the phthisical chest. 

1 Jour. Amer. Med. Assn., 1903, xl, 1196. 

2 Ibid., 1905, xlv, 2003. 

3 Muscle Spasm and Degeneration in Intrathoracic Inflammations, St. Louis, 1912, 
p. 15. 



TECH NIC OF INSPECTION AND PALPATION OF THE CHEST 267 

Technic of Inspection and Palpation of the Chest. — In addition to 
the light, warm room and stripping the patient to the waist, which 
are self-evident requirements, the patient is to be seated on a round 
stool, directly facing the window or the source of artificial light. He 
is permitted to assume his natural posture without urging him to sit 
straight up, hold his head in the middle line, etc., so that we may 
note any faulty position of the head, neck, spine and chest. Careful 
attention is to be paid to the position of the head, the shoulders, the 
clavicles, the ribs and the scapulae during rest, and during moderate 
and forced breathing. 

Above all, we are looking for evidences of asymmetry in structure, 
form, and mobility, when the two sides of the chest are compared. Motion 
can be ascertained by inspection, carefully noting from a distance the 
tips of the acromion processes, as well as the elevation of the ribs 
during inspiration, the position of the scapulae during both phases of 
the respiratory act, and also the lateral expansion of the lower parts 
of the thorax. Flattening, excavations and undue prominence of the 
respiratory muscles are to be especially looked for. The supraspinous 
and supraclavicular fossae are compared and no deviation from the 
normal should be overlooked. Spinal deformity, if present, must 
be given attention because it may be the result of an intrathoracic 
lesion; because it may have an immense influence on the results 
obtained by percussion and auscultation, and also on the skiagram. 

The motion of the anterior aspect of the thorax is well studied while 
standing behind the patient and looking over his head, watching the 
ribs and clavicles as they rise and descend during inspiration and 
expiration, and noting any retardation or limitation of motion on one 
side as compared with the other. It is, however, best to ascertain 
this by palpation, placing the hands on each side of the patient's 
neck, the thumbs meeting behind at the spine and fingers reaching 
down over the clavicles (Fig. 35), and for the lower parts by placing 
the hands over the lateral aspects of the chest. In this manner slight 
differences can be detected more easily than by inspection. Special 
attention is to be paid to lagging — one side of the chest is delayed in 
movement and, in more advanced cases, expansion is limited. At 
times we meet with both lagging and limitation of motion in various 
parts of the chest and we may conclude that the former is an indica- 
tion of a recent lesion, while the latter is caused by an old, probably 
pleuritic lesion. 

Spasm and degeneration of muscles of the neck and chest are best 
ascertained by Pottenger's method of "light touch palpation." Press- 
ing the tips of the fingers over the muscles under consideration and 
moving the hand sidewise, carefully noting the degree of resistance, 
will show this condition. While doing this the fingers should not be 
allowed to slip on the skin, because it is the condition of the muscles, 
and not of the skin, that we wish to ascertain. Over acute lesions it 
is found that the muscles give to the palpating fingers a distinct feeling 



268 



INSPECTION AND PALPATION 



of increased resistance, that they are firmer and fuller than normal, 
while over advanced lesions there is a flabby, doughy feeling and the 
bundles can be easily separated owing to atrophy and degeneration. 

Significance of Lagging. — In the very incipiency of a pulmonary 
lesion we often note that the affected side of the chest begins to expand, 
and the shoulder to move upward, later than the opposite healthy side 
of the chest, and finally does not attain the same amount of expansion. 
In far-advanced cases there may even be absolute immobility of the 
affected side. It is best ascertained by letting the patient first breathe 
normally and then asking him to take a few deep inspirations. 




Fig. 35. — Testing mobility of the chest. 



Lagging of the upper part of one side of the chest is an indication 
of a lesion in that apex, provided an acute or chronic non-tuberculous 
inflammatory process of the lung and pleura is excluded. When the 
motions of both sides are equal, but there are sure signs of tuberculosis, 
we may conclude that there is a bilateral lesion. With an old quies- 
cent lesion in one side and a new and active lesion in the other, the 
lagging is more pronounced in the newly affected side. I often find 
difficulties in clearing up by inspection and palpation old bilateral 
lesions in which both sides show limited motion. In these, percussion 
and auscultation give more reliable information. But in incipient 
unilateral cases inspection is of immense value. 



TECH NIC OF INSPECTION AND PALPATION OF THE CHEST 269 

Thoracic Asymmetry. — Looking at the phthisical chest anteriorly, 
in cases in which the disease has already made some inroads, we find 
some undue prominence, even arching of the clavicle and more or less 
deep excavation in the supra- and infraclavicular fossse, more marked, 
or exclusively, on the affected side. The angle of Louis at the junc- 
tion of the manubrium and the gladiolus is more pronounced than in 
the average healthy chest. Posteriorly, we find kyphosis in many 
cases, the scapulae are prominent, winged, and even dislocated, nearer 
the spine on the affected side. The intercostal spaces are rather wide 
and deep and, in extreme cases, the free margins of the costal carti- 
lages nearly meet in the middle line. In addition to these changes we 
meet with distortions of various parts of the chest, especially the upper 
half — flattening and retractions of various degrees anteriorly and 



Sternocleidomastoid m. . 




Scalenus post.m.^ 
Scalenus med.m.^ 
Scalenus ant.m.^ 
Trapezius m. 



Fig. 36. — Muscles of the neck which are either spasmodically contracted or atrophied 
in pulmonary tuberculosis. 



posteriorly. Depression of the acromial end of the clavicle on the 
affected side may be already noted in the very early stages of the 
disease. Kuthy 1 found it in 82 per cent, of his incipient cases. 

Spasm and Degeneration of the Thoracic Muscles. — Any, or most, of 
these changes in the contour of the chest may be noted in cases of 
non-tuberculous affections of the thoracic viscera, and also in patients 
who had a tuberculous lesion which had healed, the patient being 
in excellent health. Pottenger, in his epoch-making studies of the 
tuberculous chest, has given us certain clues as to the means of differen- 
tiating these conditions. It appears that intrathoracic conditions 
have a great influence on the muscles of respiration, a fact which 
has been known for a long time, but rationally interpreted and made 
available for diagnosis by Pottenger. 

1 Sixth Internat. Congr. Tuberc, 1908, i, 1215. 



270 INSPECTION AND PALPATION 

Whenever the lung or pleura is acutely inflamed, the thoracic 
muscles over the seat of the lesion are in a state of spasmodic contrac- 
tion, like the abdominal muscles in a case of appendicitis. Depending 
on the acuteness of the inflammatory process in the pulmonary paren- 
chyma or pleura, the muscles of the neck and chest show this contrac- 
tion in various degrees. 

Inspection and palpation reveal this condition very clearly in the 
vast majority of cases. Muscles in spasm are larger and firmer in 
appearance as well as to touch, giving a distinct feeling of increased 
tension. Often the more tendinous parts of muscles feel like distinct 
cords, while the more fleshy parts are larger and firmer to the touch 
than normal muscles on the opposite unaffected side. 

After the inflammatory process in the lung and pleura has lasted 
for some time, and passes into a chronic stage, the muscles degen- 
erate; they waste and become flabby. To the palpating finger they 
feel doughy, their normal tone or elasticity is gone, and their bundles 
are easily separated. It is important to note that, coincident with 
this change in the muscles, there is always seen atrophy of the skin 
and a disappearance of the subcutaneous tissue. Some of these changes 
are evident to the sight as well as to the touch. 

Pottenger looks upon these muscle changes as due to reflex stimula- 
tion of the motor nerves, the result of continuous irritation caused by 
the impulse from the inflamed lung and pleura. When this irritation 
is kept up very long degeneration and wasting follow, though the 
latter may be due partly to trophic disturbances. But if it is true that 
we can make out by superficial palpation of the dead body internal 
solid structures it would indicate that the theory of reflex irritation 
is inadequate. 

Muscular Changes in Incipient Cases. — In incipient cases we often 
find that the sternocleidomastoid, the scaleni, and pectoralis anteriorly 
and trapezius, levator anguli scapuli, etc., posteriorly, are in a state 
of spasm: They stand out more prominently, are larger and firmer 
to the touch than the same muscles on the opposite, unaffected side. 
I have often seen that as a result of this spasm the supraspinous fossa 
was fuller at first sight. When occupational influences can be excluded, 
it is a good sign of active incipient phthisis. When combined with 
lagging of the same region, or at the base' of the same side, it is 
undoubtedly a sign of a lesion of the lung, provided non-tuberculous 
disease can be excluded. To distinguish these changes in the muscles 
from those resulting from occupational influences, it is to be borne in 
mind that the sternocleidomastoid muscles rarely, if ever, hypertrophy 
or waste from overuse, or disuse, nor does the subcutaneous tissue show 
any changes. 

Muscular Changes in Advanced Disease. — With the advance of 
the disease, the affected muscles, as a result of prolonged spasm, 
begin to atrophy and degenerate. The result is that on inspection 
and palpation even better criteria of the intrathoracic condition may 



MUSCULAR CHANGES IN ADVANCED DISEASE 



271 



be elicited. The degeneration of the skin and subcutaneous tissue 
over the site of the lesion is seen at once; the skin can be lifted up 
with the fingers more easily, and it is felt that it lacks the normal 
elasticity. The sternocleidomastoid, scaleni, pectoralis, trapezius, 
levator anguli scapula? and rhomboidei all look smaller than their mates 
on the unaffected side. They are flabby and doughy to the touch. 




Fig. 37. — The phthisical chest. Full-blooded Indian. (Musser.) 



In cases with old circumscribed lesions limited to the upper part 
of the apex we may find the upper half of the pectoralis degenerated 
and flabby, while the lower half is normal. As a result of atrophy of 
the trapezius we find flattening of the supraspinous fossa; in extreme 
cases it appears cupped. In old cases extension of the disease may 
often be ascertained by inspection and palpation. The old lesion on 
one side shows wasting of the skin and muscles, while on the opposite 
side, where tubercles have just caused a new incipient lesion, the 



272 



INSPECTION AND PALPATION 



muscles are in spasm — contracted and prominent. Lagging is more 
pronounced on the newly affected side; it indicates an active lesion 
which hinders motion of the contracted muscles, especially the dia- 
phragm. "When palpation, percussion and auscultation show evi- 
dences of a lesion and there are changes in the mobility of the suspected 
side and no spasm of the muscles over the apex but, on the contrary, 
the tone of the overlying muscles has decreased, and there are evidences 




Fig. 38. 



-Emphysema with enlargement of the chest; the anteroposterior diameter is 
much increased. (Musser.) 



of atrophy of the subcutaneous tissue combined with clinical symp- 
toms of tuberculosis, we are justified in concluding that we deal with 
an old, inactive, or healed process." (Pottenger.) 

In many cases we may find the regional muscles more or less atro- 
phied from disuse, especially when compared with the opposite side, 
where they are enlarged, firm, and prominent because of excessive 
occupational hypertrophy. This is best differentiated by bearing in 



MUSCULAR CHANGES IN ADVANCED DISEASE 273 

mind that in muscular atrophy due to disuse, the subcutaneous tissue 
is normal, while when due to a pulmonary lesion it is atrophied. 

Effects of Muscular Atrophy on the Thorax. — Lagging, which was 
formerly attributed to lack of expansion of the affected lung or to 
pleural adhesions, is better explained by the tonic contraction of the 
scaleni and sternocleidomastoid on the affected side, which raise and 
fix the sternum, and immobilize to a certain extent the first and second 
ribs, thus limiting the respiratory motion of the affected side. Round 
shoulders, which were formerly attributed to weakness of the pos- 
terior muscles which hold the spine erect, are more rationally explained 
by Pottenger as due in a great measure to shortening of the anterior 
muscles through spasm and degeneration, together with lessened 
mobility of the thorax. Flattening of the chest, especially over pul- 
monary cavities, which was formerly attributed to atmospheric pres- 
sure forcing the bony thorax to contract, in order to occuny space 
previously occupied by lung tissue, is explained by Pottenger as due 
to inflammatory disease within the thoracic cavity, and reflex inter- 
ference with the normal motion of the diaphragm, which is known to 
be part and parcel of phthisis from radiographic studies. 

Bearing in mind that the vast majority of persons are infected with 
tuberculosis during childhood, but that the pulmonary" lesion heals, 
or remains latent, it is understood that the lesions produce muscular 
changes in the manner described above during the time of their activity. 
Thus, we have an explanation for the origin of the phthisical or par- 
alytic thorax. It is a result of an earlier infection which has healed 
or remained latent and quiescent and is not a predisposing cause of 
phthisis. A careful study of children of tuberculous parentage has 
shown that they are born with normal chests, and the characteristic 
deformity only occurs later in life after they are infected with tubercle. 

Palpation for the vocal fremitus is of no diagnostic value in any 
stage of phthisis, excepting in cases where pleural effusions are sus- 
pected. But it is often absent in thickened pleura and thus is not of 
great assistance in our attempts at differentiating the latter from an 
effusion. 



18 



CHAPTER XV. 
PERCUSSION OF THE CHEST IN PHTHISIS. 

While the value of percussion in the diagnosis of conditions in the 
advanced stages of phthisis, and its complications, is not questioned, 
it has been very seriously debated whether it can give dependable 
information in the early, or incipient, stage. Many authorities, not- 
ably of the French school, like Grancher, Bezancon, Barbier, Piery; 
and also S. West, Bonney, Lawrason Brown, Henry Sewall and others 
maintain that small tuberculous foci in the lung in incipient phthisis 
can be recognized solely through recourse to auscultation, and that 
when dulness is elicited on percussion, we may be confident that we 
are dealing with extensive infiltration — a more or less advanced stage 
of the disease. On the other hand, Aufrecht, Kronig, Goldscheider, 
William Ewart, Lees, Riviere, and many others, maintain that if we 
are to detect incipient lesions in phthisis, we must resort to percussion, 
and it is only when the process has advanced that definite auscultatory 
signs are elicited. 

Aims of Percussion. — It seems that these differences of opinion 
are mainly due to a misapprehension as to the aims of percussion. 
Those who expect to make a diagnosis relying solely on percussion 
findings will be sadly disappointed, just as they will fail in attempt- 
ing to draw final conclusions from any other single symptom or sign. 
Percussion only gives information about the density, or the air content, 
of the lung at the point examined. Whether an airless area thus detected 
is due to a tuberculous infiltration, or to one of the numerous other 
factors that may consolidate large or small areas of lung tissue, must 
be determined by a study of all the concomitant symptoms and signs. 
On the other hand, given symptoms of phthisis such as cough, fever, 
anorexia, etc., signs of a limited infiltration, or of a circumscribed area 
of airless lung tissue, elicited on percussion, may enable us to localize 
the process and complete the diagnosis in the absence of auscultatory 
signs. 

We must bear in mind that phthisis does not begin as a catarrh of 
the small bronchi, as some believe, but as an infiltration, transforming 
the normal porous, air-containing, and resonant lung into solid non- 
resonant tissue. At this stage the alveoli are filled with exudate, or 
the interstitial tissues contract and compress the alveoli, finally 
obliterating them altogether. Inasmuch as altered breath sounds and 
rales can only be found in the pulmonary apices when edema and 
secretions interfere with the entrv or exit of the air current while 



AIMS OF PERCUSSION 



275 



passing through the air vesicles and bronchioles, it is clear that auscul- 
tation may not give any information at a very early stage. So long 
as the infiltration remains beneath the mucous membrane of the 
bronchi, the entrance of air into the alveoli of the affected area is not 
interfered with very much, while in the rest of the lung it is freely 
circulating. Auscultation may not reveal such a lesion which is sur- 
rounded by healthy lung tissue working vicariously and sucking in 
more air. 




Fig. 39. — Outlines of viscera. The margins of the lobes of the lungs are shown 

(interrupted line ); solid black line, heart, liver, and spleen; stomach shaded. 

(After His-Spalteholtz, Luschka, and Musser.) 



It is only when the caseous material of the infiltrate softens and 
breaks through the wall of a bronchus, thus permitting the entrance 
of air into the disease focus proper, that rales can be heard on auscul - 
tation. At that time tubercle bacilli make their appearance in the 
sputum. When we have rales we may be sure that we are dealing 
with a more or less advanced stage of the disease — caseation and 
softening have already taken place. 

When the tuberculous process was not located originally in the bron- 
chioles, but in the peribronchial tissues, it is again evident that the air 
circulating in the bronchial tree cannot reach the tubercle at all, and 
the auscultatory signs will necessarily be negative. At most, feeble 



27G 



PERCUSSION OF THE CHEST IN PHTHISIS 



or the absence of breath sounds over a limited area may be the first sign 
elicited. 

Technic of Percussion. — Percussion has been neglected by many 
because it has not given them the information they sought; at times 
it even misinformed them. The reason is almost invariably faulty 
technic. Before giving details .as to percussion findings in early 
phthisis, we must speak about the proper technic to be followed in 
apical percussion. 




Fig. 40. — Outlines of viscera. The margins of the lobes of the lungs are shown 

(interrupted line ); solid black line, heart, liver, and spleen. (After His-Spalte- 

holtz, Luschka, and Musser.) 






The first and most important point in percussion is a light stroke with 
the finger. Heavy blows with two or three fingers are ivorse than useless. 
Because of the elasticity of the thoracic walls, a great part of the per- 
cussion stroke is always dissipated along the muscular and bony 
parietes, and when we strike a heavy blow most of the force is con- 
ducted laterally by the ribs and intercostal muscles, which are set into 
strong vibration, acting as large pleximeters, and resonance from all 
the lung beneath them is elicited. Small areas of airless tissue are thus 
overlooked. With a light stroke the force is not conducted along the 



TECH NIC OP PERCUSSION 



277 



parietes, but penetrates sagitally into the lung, affording information 
about its condition immediately beneath the point examined. 




Fig. 42 



Figs. 41 and 42. — Margins of the lungs and of individual lobes, dotted line ( ) ; 

limits of pleural sacks, interrupted line ( ); liver and spleen, solid black line; 

diaphragm, starred line (******); stomach (portion not covered by lung) shaded, 
(After Luschka and Musser.) 



With light percussion in which the stroke is gentle and soft, hardly 
audible at any distance, we can always localize areas of superficial 



278 PERCUSSION OF THE CHEST IN PHTHISIS 

dulness. Deep-seated, airless areas cannot be detected by heavy per- 
cussion, as is evident from the fact that we cannot map out the heart 
from behind, and in obese and edematous persons it is quite difficult, 
often impossible, to define the boundary between the liver and the 
lung. Strong blows do not reach much deeper into the pulmonary 
tissue proper than light strokes. To be sure, they set up stronger 
vibrations, but mainly in a lateral direction and for this reason the 
penetrating power of the heavy blow may be even less than that of 
the light stroke. 

Gentle percussion often brings out small areas of dulness which dis- 
appear with an increase in the force of the blow because larger areas 
have been set into vibration. This point is utilized for diagnostic 
purposes : If, on increasing the force of the blow, the dulness remains, 
we may be sure that we are dealing with extensive areas of airless 
tissue. 

The Pleximeter Finger. — Light percussion is best accomplished when 
the movement of the percussing finger is exerted only from the meta- 
carpophalangeal joint. The note elicited should be only a faint sound 
which can be heard when listening attentively. Of course, perfect 
silence must be maintained in the room. When reaching an airless 
area, the contrast between the resonance evoked in the air-containing 
space and the deadness over the dull area is striking. The contrast 
between something and nothing is easier of appreciation than the 
difference between one thing and another which differs but slightly 
from it. Over resonant areas we evoke a note, while over dull areas 
no note is brought out at all. 

Strong pressure of the pleximeter finger on the chest wall dissipates 
the advantages of light percussion by bringing the intercostal muscles 
into tension, making them large pleximeters, which elicits resonance 
of the neighboring air-containing lung, and small areas of dulness can 
thus not be delineated. Very light contact of the pleximeter finger 
with the chest wall is therefore important; in delicate percussion, the 
mere weight of the finger is sufficient. 

Bearing in mind that, as a rule, tuberculous lesions spread from 
above downward, and that the line between the healthy and infiltrated 
tissue usually runs horizontally, we must percuss from above down- 
ward, or the reverse, in horizontal zones. The pleximeter finger should 
be placed parallel with the ribs (Fig. 43), and not perpendicular to them, 
as is often done. It is obvious that when the pleximeter finger is placed 
vertically on the chest we obtain mixed resonance, because the stroke 
brings both healthy and diseased lung into vibration in cases of limited 
lesions. Only intercostal spaces should be percussed because percussion 
of the ribs, which in themselves are to be considered as long plexi- 
meters, brings out resonance due to vibrations of large areas of lung 
tissue which lie laterally, and not only from beneath the spot which 
we intend to strike at the given moment. 

The usual way of beginning percussion at the top of the chest and 






TECH NIC OF PERCUSSION 



279 



going gradually downward to the base has many disadvantages. It 
is much better to percuss from below upward. N. K. Wood 1 sum- 
marizes the reasons for this procedure as follows: "It is much easier 
for the ear to pick up a higher note from a lower than it is to do the 
reverse; it requires a much lighter stroke to bring out the normal 
note than the pathological; it is the rational plan to work from the 
normal as a standard toward the pathological. The reverse leads to 
faulty standards. The apices, as is well known, are most frequently 
affected and more rarely give a normal note. To start at the apex, 
therefore, is usually to commence with a pathological note. This 
prejudices the further examination. With downward percussion, the 




Fig. 43. — Percussion of the right apex. 

higher note merges into the lower too imperceptibly to do accurate 
work. This is so for two reasons: (1) the mind becomes prejudiced in 
favor of a pathological note and consequently does not attempt to 
make fine distinctions, (2) a heavier stroke is required for the patho- 
logical note and when the more resonant is reached, the percussion is 
continued too heavily to detect what should be readily appreciated 
differences in the force of stroke necessary to bring out a good note. 
In this way the examiner deprives himself of a very important guide 
to collect accurate data." 



Jour. Am. Med. Assn., 1914, lxiii, 1378. 



280 



PERCUSSION OF THE CHEST IN PHTHISIS 



The Hooked-finger Pleximeter. — In incipient phthisis we aim at 
localizing the smallest possible area of dulness, and at times the plexi- 
meter finger is too large for the purpose. Plesch 1 has suggested that the 
pleximeter finger be flexed at the second phalanx to a right angle, the 
pulp only is applied to the chest and the distal end of the first phalanx 
is percussed (Pig. 44). This maneuver also enables the delimitation 
of the boundaries of the apex, or the determination of the condition of 
the apex behind the heads of the sternocleidomastoid, which is often 
of great importance. 

Position of the Patient. — The patient should sit on a revolving stool, 
or better stand up with his head in the middle line, arms hanging by 
the side in a relaxed condition (Fig. 45). Contraction of any of the 
muscles of the chest on one side may greatly interfere with the results. 
When the back is percussed the patient is asked to fold his arms each 
on the opposite shoulder with a view to removing the scapulae as far 
outward as possible. With these bones in the normal position the 




Ficj. 44. — Hooked-finger percussion. 

greater part of the lung in the supraspinous fossae is beyond the bony 
thorax, and the apex is partly covered by the shoulder-blades. To 
hammer away in the supraspinous fossae, as we often see done, is a 
waste of time and energy, because percussion there strikes bone and 
thick muscles, and the waves hardly, if at all, penetrate into the lung. 
But w T ith folded arms, each over the opposite shoulder, or the patient 
embracing the back of a chair, the shoulder-blades are moved far 
away from the median line of the body, thus exposing the lung covered 
by comparatively thin parietes. 

W 7 hen it is desired to bring out the finer shades of resonance or, in 
doubtful cases, it is advisable to have the patient lying down on an 
upholstered couch or an examining table. Placing the patient with his 
back near a w T all or door, or, as Lawrason Brown suggested, standing 
in the angle between two walls, may help in bringing out points which 
might otherwise escape attention. 



Munchen. med. Wchnschr., 1902, xlix, 620. 



COMPARATIVE PERCUSSION 



281 



Comparative Percussion. — When percussing, we compare sym- 
metrically corresponding areas on both sides of the chest and percuss 
with equal force while striking each side. This is especially important 
because there is no standard resonance for a healthy chest; every 
individual has his own resonance which depends on many factors, 
mainly the vibration of the chest walls and the contents of the thoracic 
cavity, which are inconstant values. But in the normal chest the reso- 
nance, as well as its qualities such as duration and pitch, are practi- 
cally the same on both sides. 

In incipient cases there are " seats of election" — points where 
dulness is most likely to be encountered if there is an apical lesion. 




Fig. 45. — Percussion of the left apex posteriorly. 



Anteriorly, it is mostly under the inner third of the clavicle, and 
posteriorly at the inner margin of the upper half of the scapula. 

A small area of defective resonance can often be discovered by 
immediate percussion directly over the clavicle, comparing one side 
with the other. Immediately above and below the clavicle mediate 
percussion will bring it out, if it is present. If, on light percussion, 
impairment of resonance is discovered, the force of the blow is dimin- 
ished to a minimum, thus delimiting the affected area, and we can again 
percuss the same spot, gradually increasing the force of the blow, 
always having in mind the thickness of the integuments, with a view 
to ascertaining the degree of dulness. If the dulness disappears with 



2S2 



PERCUSSION OF THE CHEST IN PHTHISIS 



a heavy stroke, the lesion is of slight extent and superficial, or there 
may be a thickened pleura; but if it persists, we may feel confident 
that we are dealing with an extensive area of airless tissue. 

Posteriorly, we look for dulness over the apices of the upper and 
lower lobes of the lung. The former is located in the supraspinous 
fossa near the spine and reaches the first thoracic spine; the latter 
is lower in the right side, reaches the fourth thoracic spine and higher 
in the left side at the third thoracic spine (Fig. 49). If impairment 
of resonance is present in incipient cases, it will be found at one of 
these four points. 




Fig. 46. — Hooked-finger percussion of the apex. 

While doing comparative percussion of apices it is imperative to 
remember that, in the majority of healthy persons, the resonance over 
the right apex above the third rib is somewhat defective; the note is 
shorter and of higher pitch. This has been attributed to various 
causes. The recent investigations of George Fetterolf and George W. 
Norris 1 have shown that it is due to the anterior position of the large 
vessels in relation to the right apex, as compared with the left; to the 
consequent encroachment upon, and reduction in size of, the right 
apex and to the contact of the inner surface of the right apex with the 
resonating trachea, while the left is in contact with non-resonating 

1 Am. Jour. Med. Sc, 1912, cxliii, 637. 






TYMPANITIC RESONANCE IN INCIPIENT LESIONS 



283 



solid tissue. In right-sided lesions, when the signs are inconclusive, 
topographical percussion is therefore best. 

Tympanitic Resonance in Incipient Lesions. — In the early stages 
the absence of distinct dulness in any part of the thorax is not always 
an indication of the absence of tuberculous infiltration. Impairment 
of resonance can only be brought out when the focus is at least one 
inch in diameter, although some, like Flint and Oestreich, are said to 
have detected smaller foci. But small disseminated tubercles, before 
they become confluent, may alter the resonance in an altogether 
different direction. Causing relaxation or hyperfunction of the sur- 




Fig. 47. — Percussion of the axilla. 



rounding lung tissue, they impart a tympanitic note on percussion. 
This tympany is of great importance in the diagnosis of incipient 
lesions, and is usually the cause why two competent observers will at 
times detect the lesion on different sides of the chest. 

Everyone who has had the opportunity and inclination to watch 
incipient tuberculous lesions has met with cases in which the first sign 
obtained on percussion is localized tympany, which subsequently 
changes into dulness with a tympanitic overnote, and finally becomes 
dull. Tympany in one supraspinous fossa, when accompanied by 
suspicious symptoms, is to be taken seriously; it may be the sole 
indication of small disseminated tubercles. 

Absence of percussion signs, on the other hand, does not exclude 



284 



PERCUSSION OF THE CHEST IN PHTHISIS 



incipient phthisis, because the lesion may be located deeply, subapic- 
ally, or centrally, or it may be altogether a more malignant process — 
miliary, or disseminated, tubercles all over the lungs which have not 
yet become confluent. In the same manner, extensive tympany over 
one lobe, or one lung, with fever, cough, etc., may be an indication of 
extensive tuberculization of the affected part. The outlook is not so 
good as when the tubercles are localized in a limited area. 

Respiratory Percussion. — In doubtful cases it is advisable to study 
the changes in the resonance during extreme and held inspiration and 
expiration, as was suggested by J. M. Da Costa 1 over forty years ago. 




Fig. 48, — Lung margins according to Goldscheider. 

He showed that -*at the apices, and especially in the infraclavicular 
region, in the supraspinous fossa?, and on a line toward the spine, a 
full-held inspiration increases the resonance, makes the sound fuller 
and raises the pitch; and where, as is so common, the left side has 
normally a higher pitch, this disparity is preserved." A held and 
complete expiration will greatly lessen the resonance and lower the 
pitch at the apices. "In the held inspiration we obtain a greater mass 
of tone; in held expiration, the reverse." This change of resonance 
was found by Da Costa to remain unaffected in bronchitis; but in 



Am. Jour. Med. Sc, 1875, lxx, 17. 



TOPOGRAPHICAL PERCUSSION OF PULMONARY APICES 285 

phthisis, even in the earlier stages, the affected area shows the reverse 
—a long-held inspiration gives a duller note than that observed on 
the healthy side. 

This change of note during held inspiration and expiration is brought 
out very clearly by light percussion and is of great value in doubtful 
cases. When the infiltration increases in extent, involving the larger 
part of the apical parenchyma, the dulness on percussion is no longer 
modified by the forced and held expiration and inspiration. Hence we 
have in this method a very good test as to the extent of involvement 
in the tuberculous process. Aufrecht 1 confirmed these findings. 




Fig. 49. — Lung margins according to Goldscheider. 

Topographical Percussion of the Pulmonary Apices. — There are 
cases of incipient phthisis in which comparative percussion gives no 
conclusive information, and only topographical percussion — mapping 
out the limits of the apical resonance — may clear up the case. This 
can only be done intelligently when we have clear ideas as to the limits 
of these resonant areas in the healthy person. 

Kronig 2 showed that the resonant areas project as cones anteriorly 
and posteriorly, and that these two cones are united on the top of the 
shoulders by a narrow strip of resonance — the isthmus (Figs. 50 and 



1 Berl. klin. Wchnschr., 1912, xlix, 101. 

2 Deutsch. Klinik, 1907, xi, 581 and 634, 



286 



PERCUSSION OF THE CHEST IN PHTHISIS 



51). With careful and very light percussion we can easily map out 
the mesial line which runs in front, beginning at the sternoclavicular 
articulation, upward and outward forming a concavity inward, while 
posteriorly the line forms a convexity and ends at the level of the lower 
border of the second thoracic spinous process. The external line sepa- 
rating the resonant apex from the dull shoulder and neck runs from 




Fig. 51 
Figs. 50 and 51. — Kronig's apical resonant areas. 



the middle of the anterior border of the trapezius, curving downward 
and reaching the clavicle at the junction of the middle and outer thirds 
and continuing obliquely downward toward the axilla; proceeding 
upward, it forms a convexity toward the neck, crossing the shoulders, 
on the top of which it is separated from the mesial line by a resonant 
space of about 2 to 3 cm. forming the isthmus, and proceeding downward 
with its concavity outward, terminating a couple of centimeters out- 



CHANGES IN APICAL RESONANCE IN PHTHISIS 



287 



side of the middle line of the scapula. Normally the height of the 
apex is anteriorly about 2 to 3 cm. above the clavicle, and posteriorly, 
on a level with the first thoracic spine, about 2 cm. outside of the 
middle line of the body. 

It is important to remember that the pleximeter finger should be 
applied parallel with the line we expect to delineate; in this case at 
right angles with the clavicle. It is also better to percuss from the 
lower parts of the chest upward, because in the former the normal 
note is usually found in early cases and it is always best to compare 
normal resonance with defective by striking the former first, as was 
already indicated. 




Fig. 52. — Contraction of the resonant area of the left apex. 



Changes in Apical Resonance in Phthisis. — When the resonant 
areas are marked out on the chest of a healthy person, their height 
and width are practically the same on both sides. But in phthisis one 
side will be found contracted. Recalling that a tuberculous lesion in 
the apex involves shrinkage of the pulmonary parenchyma, we have 
an explanation for this phenomenon. The extent of the shrinkage 
depends on many factors, mainly the degree of pulmonary retraction 
and the location of the lesion. When the lesion is centrally located, 
shrinkage of the apex is greater than when it is located at the periphery 
or under the pleura, as has been shown by Oestreich, obviously because 
in the former case traction is exerted on all sides. Autopsy findings 



288 



PERCUSSION OF THE CHEST IN PHTHISIS 



show conclusively that this shrinkage occurs quite early, much earlier 
than is generally appreciated, and for this reason we may get a clear 
view as to the condition of the lung in that region, by percussing the 
apices and mapping out Kronig's resonant areas. 

Shrinkage manifests itself in two ways: 

1. By a narrowing of the field of resonance on the affected side. 
This can be established by actual measurement. The isthmus in 
healthy persons is about 2 to 3 cm. in width, and when we find it less 
than 1.5 cm. in width, it requires investigation. The width of the 
base of the resonant cone may be measured simply in finger-breadths, 




Fig. 53. — Kronig's resonant areas, showing a band of doubtful, or relative resonance 
at the mesial border of the left apex; also retraction of the lower margin of the left 
lung. 

as has been recommended by R. N. Philip. 1 Both sides are to be of 
the same width. 

2. By a blurring of the line separating the resonant from the dull 
parts (Figs. 53 and 54). While in health we can easily percuss out a 
clear line of demarcation, in tuberculous apices there is often an 
interval in which the resonance is doubtful. This is mostly found at 
the inner outline, but may be found at both sides. Kronig attributed 
it to changes in the tension of apical parenchyma at the margin of the 
affected parts. These points are better illustrated than described 

» Edinburgh Med. Jour., 1907, xxii, 473. 



CHANGES IN APICAL RESONANCE IN PHTHISIS 



289 



(Fig. 55), and in practice after the outlines of the apices have been 
marked out with a skin pencil, any existing differences in the outlines 
of the apices when one side is compared with the other are noted at 
a glance and need no measuring. 

Sources of Error. — Kronig's method is of excellent service in most 
cases of incipient phthisis. But we often meet with cases in which 
after careful and time-consuming work, the results attained are unsat- 
isfactory. I have seen cases of phthisis in which no dislocation of any 
of the outlines of the apical resonance could be made out. Then, 
there are numerous cases in which contraction of the apex is made 
out very nicely, but there is no active phthisis. This is especially 




Fig. 54. — Bands of doubtful resonance on both sides cf the right apex anteriorly. 



true of " collapse induration," which will be discussed later on. Healed 
tuberculous lesions also leave contracted apices and what we seek 
to determine is the presence of active phthisis. Walter C. Klotz found 
differences in the two sides very frequent in non -tuberculous indi- 
viduals; the right side is often narrower, regardless of the site of the 
more extensive lesion. His conclusion, which is in agreement with our 
experience, is to the effect that unless the disparity of the apical per- 
cussion field, expressed in terms of Kronig's isthmus, is very marked, 
it does not necessarily point toward tuberculosis of the corresponding 
side. Such a disparity is also of less significance on the right side 
than on the left. 
19 



290 



PERCUSSION OF THE CHEST IN PHTHISIS 



Kronig stated that in phthisis the motion of the base is invariably 
affected at an early stage, while in non-tuberculous apical lesions 
the expansion of the lower margins of the lung remains normal. This 
does not hold in practice. There are many cases of phthisis in which 
the base retains its normal mobility during inspiration and expira- 
tion, and the reverse. The reason for the occasional failure of this 
method of percussion lies in the fact that the resonant area is not an 
outline of the true anatomical apex, but merely a projection of the 
same lung tissue in various directions (Figs. 57 and 58). The fact is 
that it is impossible to project the top of the lung on the surface of the 
body, considering its peculiar anatomical position and form. Kronig's 




Fig. 55. 



-Frequent findings with Kronig's method of percussion in advanced cases. 
Retraction of the left lung. 



isthmus, for instance, does not exist at all, and we must remember 
that only the mesial border corresponds to the anatomical margin of 
the lung anteriorly and posteriorly. The lateral border cannot be 
determined with exactness in most cases because the percussion wave 
strikes the spot tangentially. In patients with marked scoliosis, the 
method is of no value at all. 

Goldscheider's Method of Apical Percussion. — Anatomical studies by 
Goldscheider, 1 as well as orthodiagraph^ examination of the lungs 
in their relation to the bony thorax, show T conclusively that there is 

i Berl. klin. Wchnschr., 1907, xL 1267 and 1309. 



CHAXGES IX APICAL RESONANCE IN PHTHISIS 



291 



no lung tissue in most of the resonant area percussed out by Kronig's 
method. Anteriorly, the apex lies beneath the two heads of the sterno- 
cleidomastoid, protruding above the inner third of the clavicle for 
about one inch in height. This is seen clinically when emaciated per- 
sons cough and the lung is blown up above the clavicle, or in wasted 
infants during crying spells. Posteriorly, the apex of the lung lies 
close to the spinal column, reaching as high as the spinous process 
of the first thoracic vertebra. But there it is impossible to obtain 
resonance from it because it is covered by a bony transverse process, 
rib and thick muscles. 




Fig. 56. — Same patieDt as in Fig. 59; findings posteriorly. 



Goldscheider, 1 for these anatomical reasons, devised another method 
of obtaining the resonance of the true anatomical apex, which we dis- 
cussed in detail elsewhere. 2 From the complicated procedure of Gold- 
scheider all that is of utility in doubtful cases is the determination 
of the height of the apex between the heads of the sternocleidomas- 
toid, which can easily be done by percussing from below upward with 
the hooked finger as a pleximeter and comparing the two sides. Pos- 
teriorly, the lung resonance should reach the tip of the spinous process 
of the first thoracic vertebra on both sides. The height of the apices 
on both sides normally should be the same, and if it is found shorter 



1 Ztschr. f. klin. Med., 1910, lxix, 205. 

2 New York Med. Jour., 1913, xcvii, 799. 



292 



PERCUSSION OF THE CHEST IN PHTHISIS 



on one side, it demands investigation as to the cause. In connection 
with other symptoms, it is strongly in favor of tuberculosis. But here 
again, it may be an old, healed lesion. The distinction between active 
and healed lesions is made by means other than percussion. 

Tidal Percussion. — After ascertaining the limits of the apices, the 
base is to be delineated with a view to determining the vertical move- 
ments of the lung in the pleural sinus during both phases of respira- 
tion. This gives us infonnation as to the presence or absence of 




Fig. 57. — Showing that Kronig's resonant areas are not outlines of the apical margins, 
but are merely projections of the same lung tissue in various directions. (After Gold- 
scheider.) 



emphysema, especially in fibroid phthisis, pleural adhesions, which 
are of such immense interest when contemplating the application of 
a therapeutic pneumothorax, etc. 

The lower margins of the lung resonance are first ascertained by 
percussion while the patient breathes normally and quietly, and marked 
with a dermographic pencil. Then the patient is directed to take a 
deep breath, and hold it as long as possible, while we again percuss 
and ascertain the lower limits of the lung, and again mark them with 
the pencil. In healthy persons the difference in these two lines is 
between one and two and a half inches. It is to be borne in mind that 



TIDAL PERCUSSION 



293 



on the left side the lung margin is naturally about an inch lower 
than on the right; also that the expansion is greater in the axillary 
line anteriorly than posteriorly. In emphysematous subjects, also in 
the senile, and in those with deformed chests, expansion may be very 
little or nil. Pain while breathing may have the same effect. On 
the left side, when there is no expansion anteriorly at Traube's semi- 
lunar space, it is an indication of pleural adhesions, or effusion; an 
increase in the tympany at that space indicates retraction of the left 
lung, not infrequent in phthisis. 




Fig. 58. — ShowiDg that Krone's resonant areas are net outlines of the apical margins, 
but are merely projections of the same lung tissue ir various directions. In the supra- 
spinous fossae there is no.hmg tissue at all. (After Goldscheider.) 



In most cases of incipient phthisis the. respiratory excursion of the 
affected lung is more or less restricted, and when there are adhesions, 
there is unilateral absence of respiratory excursions. But since we 
have been interested in pleural adhesions while making artificial 
pneumothorax, we find that these signs are not absolutely reliable. 

Percussion in Advanced Phthisis. — With the advance of the disease 
the percussion findings become more and more varied and scattered 
all over the chest, and the difficulties of determining the exact condi- 
tion of the lungs from percussion findings alone, more and more unsur- 



294 



PERCUSSION OF THE CHEST IN PHTHISIS 



mountable. The dulness elicited is usually due not only to the active 
lesions, but also to such as have healed or are quiescent; to thickened 
pleura, which is usually a conservative process; to pleural effusions, 
displacements of the heart, diaphragm, liver, stomach, etc. Some 
of these processes are permanent, others appear for a short time and 
disappear. Localized emphysema, transient or permanent, due to 
vicarious function, often obscures deeply lying airless tissue. 

In most cases, however, we find that one lung shows dense dulness 
in its upper part, usually as far as the third or fourth rib, as well as 
retraction of one or, more rarely, both bases. But even this may be 




Fig. 59. — Topography of the apex according to Goldscheider : upper and mesial 

borders of the lung; borders of the first rib and clavicle. On the left side the 

clavicular head of the sternocleidomastoid has been removed so that the scalenus anticus 
is visible. The upper border cf the lung is somewhat higher than the first rib. 



due to healed or quiescent old lesions. We also find a frequent area 
of dulness in one and, at times, in both interscapular spaces due to 
lesions of the apices of the lower lobes, or enlarged glands. At times the 
dulness runs along the lines of the interlobar fissures anteriorly and 
posteriorly. To map out such areas of dulness may be of scientific 
interest, but the diagnosis of these cases rests on other methods of 
exploration, especially the subjective symptoms. Signs of excavation 
are discussed elsewhere. (See Chapter XX.) 

Sources of Error in Signs Elicited by Percussion. — When finding 
defective resonance over one apex, contraction of Kronig's resonant 
area on one side, or one apex shorter than the other, thus indicating 



diagnostic value of percussion 295 

pulmonary retraction, are we justified in considering the patient sick 
with active phthisis? Are differences in resonance elicited when the 
two sides of the chest are symmetrically and comparatively percussed, 
especially in its upper third, sure indications of active phthisis? 

These problems confront the clinician quite often, and they can 
only be answered by an intelligent consideration of the causes of 
defective resonance and dulness, which are mainly airless lung tissue, 
and which may be due to many other causes in addition to tuberculosis. 
Besides, we may have differences in the resonance due to faulty technic 
in percussion, also because of asymmetry of the chest in cases of 
kyphosis or scoliosis, or unilateral hypertrophy of the muscles due to 
occupational effects. These factors are to be eliminated before we 
attempt to interpret percussion findings in early phthisis. 

There are other sources of error. Chronic pneumonic processes, 
healed apical lesions and pleurisy are very common, as we have 
already shown, and many leave some airless tissue which is detected 
by careful percussion. So that even if due to tuberculosis, apical 
dulness or retraction does not always mean active phthisis requiring 
therapeutic intervention. Collapse induration, due to inhalation of 
dust in mouth-breathers, may show percussion signs which are undis- 
tinguishable from phthisis, if we should rely on percussion alone. 
We also occasionally find dulness in the apices in persons leading 
a sedentary life, and who do not breathe deeply, especially chlorotic 
girls. Some of these cases are cleared up by directing the patient to 
breathe deeply for some minutes, or practising Da Costa's respiratory 
percussion. 

We also meet now and then with persons in whom the resonance 
on one or both sides of the chest is defective without any excessive 
adiposity or strongly developed muscles to account for it. The air 
content of the lungs is less in childhood than in later life, and it 
decreases with old age, often without showing any anatomical changes 
in the lungs at the autopsy. 

In many cases a* study of the overlying muscles as to rigidity and 
atrophy has helped me immensely, while in others it was of no avail. 

Diagnostic Value of Percussion. — In cases presenting symptoms 
of phthisis such as fever, cough, nightsweats, etc., percussion findings 
alone are often sufficient to localize the lesion, and in many cases it 
will be found by prolonged observation that a lesion develops in the 
apex where we originally found only defective resonance or contrac- 
tion of the field of resonance, though auscultatory signs were wanting. 

Percussion findings alone, without any general symptoms of phthisis, 
prove nothing, just as in radiography a shadow over an apex does 
not prove an active tuberculous lesion. It is only in connection with 
the general symptoms that percussion, like any other single sign or 
symptom, can be utilized for diagnosis. 

However, whenever found, defective resonance in an apex demands 
careful investigation and watching of the case, unless a reason is found 
for its existence. 



CHAPTER XVI. 
AUSCULTATION OF THE CHEST IX PHTHISIS. 

We have shown that percussion is a most valuable diagnostic method 
in early phthisis, even more valuable than in the later stages, and will 
often give definite information as to the air content of the lungs much 
earlier than other methods. Auscultation is just as valuable for 
other reasons. At times it affords information in cases in which the 
lesion is centrally located, and in tuberculosis grafted on an emphy- 
sematous lung, when percussion and even skiagraphy may fail. 
Similarly, in advanced cases where the lesion is extending, altered 
breath sounds and rales may often be found in advance of dulness. 
On the other hand, acute cases, especially miliary tuberculosis, may 
show normal breath sounds and no rales, and in chronic cases with 
deeply lying cavities the normal lung tissue conceals all the signs of 
excavation. In the former diffuse tympany, while in the latter per- 
cussion or radiography, may disclose the exact state of affairs. 

Believing that the technic of auscultation is much easier to master 
than that of percussion, many have discarded the latter and rely 
solely on the former, which is a grave error. The fact is that it is just 
as difficult to acquire skill in proper auscultation of the chest, and in 
interpreting the findings correctly, as to percuss properly. Some, like 
Goldscheider 1 and Give Riviere, 2 believe that auscultation is even more 
difficult to master. It is because of faulty technic that auscultation 
does not yield all the information that can be obtained by this method. 

Technic of Auscultation. — The patient should be stripped to the 
waist, just as for percussion, and seated on a high revolving stool, 
so as to be accessible from all sides. Before beginning auscultation 
the physician must assure himself that the patient knows how to 
breathe properly and if not, which is very often the case, proper 
instruction is to be given objectively. One important drawback to 
auscultation is that many patients do not know how to exhale — they 
just inspire jerkily, and stop with inflated chests. Others, usually 
such as have led a sedentary life and never expanded their chests 
properly, inhale and exhale quickly in rapid succession so that it is 
difficult to follow each phase of respiration. While in the vast majority 
a little instruction suffices, at times we meet with some, and not 
exclusively among those reputed to be ignorant, who will not breathe 
properly forour purposes, especially nervous individuals, and the 

1 Ztschr. f. klin. Medizin., 1910, lxix. 205. 

2 Early Diagnosis of Tubercle, London, 1914, p. 22. 



SINGLE PHASE AUSCULTATION 297 

examination must be postponed till they become accustomed to the 
physician. 

The breathing- must be regular, rhythmic, somewhat deeper than 
usual, and through the nose, because when the air enters this way the 
lungs expand much better and more uniformly. Mouth-breathing 
occasionally induces cough. In cases of nasal obstruction the patient 
breathes through his mouth, but we must guard against noises arising 
in the pharynx, especially those created by the soft palate, which 
impart a bronchial or blowing character to the breath sounds and, 
at times, give an impression of prolonged expiratory murmur, when 
in fact there is nothing of the kind. 

Special attention should be paid to expiration, during which the 
patient should empty his chest as much as possible, without any 
undue exertion, and that each expiration should promptly be followed 
by a deep inspiration. 

Any stethoscope to which the physician is accustomed may be 
used. The writer prefers the Bowles model, and the one devised by 
J. J. Singer, of St. Louis, has given satisfaction. The bell should be 
applied carefully in the intercostal spaces, especially in emaciated 
persons, so that it makes an air-tight connection with the skin. It 
should be held firmly but without any undue pressure, thus excluding 
all extraneous noises. Movement of the bell of the stethoscope upon 
the surface of the body interferes greatly with proper auscultation 
and should be avoided. 

Single Phase Auscultation. — To appreciate slight changes in the 
duration and quality of the respiratory murmur it is important to 
listen to each phase of the respiratory act separately. Grancher's 1 
method has served me best. It consists in first listening to the inspira- 
tory murmur and to neglect at the time the expiratory murmur; and 
when listening to the latter the former is to be neglected. Rales are 
always looked for separately, after we have a clear idea as to the 
character of the breath sounds. 

Beginning, for instance, with auscultation of the left apex, we 
listen attentively to the inspiratory murmur, and while the patient 
exhales, the bell of the stethoscope is quickly carried over to a cor- 
responding point on the right side of the chest, and we listen to an 
inspiration. The inspiratory murmur is thus compared right and 
left, and any differences that may be found are carefully noted. In 
this manner the slightest change in the murmur on one side can be 
best appreciated, because we have a standard in the unaffected side. 
Only when both sides of the chest are affected is this method unin- 
structive, because we do not have an immediate impression of a normal 
inspiratory murmur. The expiratory murmur is to be studied in the 
same manner, carrying over the bell of the stethoscope while the 
patient inspires, and noting the difference. While listening to these 

1 Maladies de l'appareil respiratoire, Paris, 1890. 



298 AUSCULTATION OF THE CHEST IN PHTHISIS 

murmurs, no attention at all is paid to any adventitious sounds which 
may be present. These are left for separate study. 

This method of auscultation, devised by Grancher, and hardly ever 
mentioned in our text-books, is the only one that can bring out all the 
changes in the respiratory murmurs heard in really incipient pulmonary 
lesions, and should be used exclusively. 

The Normal Respiratory Murmurs. — The most important prerequi- 
site of proper interpretation of auscultatory findings in pathological 
conditions of the lungs is a knowledge of, and experience with, the 
respiratory murmurs audible in normal chests. Without this knowl- 
edge we cannot expect to appreciate slight changes audible during 
either phase of the respiratory act in early phthisis. It is because of 
the disregard of the qualities of the physiological breath sounds that 
slight changes are overlooked, and many state that only with the 
appearance of adventitious sounds can a positive diagnosis be made, 
which is decidedly wrong, just as is waiting for tubercle bacilli to make 
their appearance in the sputum. One who wants to appreciate the 
early changes of phthisis cannot auscultate normal chests too often. 

The physiological, or vesicular, respiratory murmur shows that the 
pulmonary parenchyma at the auscultated area contains air which 
enters with each act of inspiration and leaves with each act of expira- 
tion without meeting any obstruction in its course. During inspira- 
tion it is audible with different degrees of intensity all over the chest 
as a sighing, whispering rustle; during expiration there is either no 
murmur at all, or, more commonly, a very faint noise is heard which 
is somewhat lower pitched than, and it lasts but one-fifth the time of, 
the inspiratory murmur, notwithstanding that expiration actually 
lasts longer than inspiration. 

Without entering into the problem of the origin of these murmurs, 
whether they are produced in the glottis or in the air cells in the 
areas under examination, we want to emphasize that it is important 
to bear in mind while auscultating that any changes in pitch, quality 
and rhythm noted during either phase of respiration are to be given 
careful attention in cases in which early phthisis is suspected. 

Feeble Breathing. — When meeting a patient with a really incipient 
lesion, which is not often our privilege because when they present 
themselves the lesion is usually more advanced than is generally appre- 
ciated, we find no adventitious sounds, no changes in the type of 
breathing, no broncho vesicular or bronchial breathing, etc. The 
most common change in the breath sounds at this stage is feeble 
breathing, or, more rarely, complete absence of the respiratory mur- 
mur over a circumscribed area in one of the apices, mostly found 
posteriorly near or above the spine of the scapula, the zone d'alarme 
of some French authors, 1 and anteriorly beneath the inner third of the 
clavicle. At times this feeble murmur is blowing or even bronchial in 

* Sergent, Le Monde Medical, 1912, xxii, 1121; La Clinique, 1913, viii, 437. 



FEEBLE BREATHING 299 

character and at the end of inspiration some dry crackling may be 
heard. 

It is noteworthy that while very few modern authors mention feeble 
breath sounds in incipient tuberculosis, the great French clinician of the 
first half of the nineteenth century, Andral, already considered it a good 
and reliable sign. He says: "We have ascertained weakness of the 
respiratory murmur, or even its total absence, in points where, after 
death, we found tubercles scattered in greater or less number in the 
midst of the pulmonary parenchyma very much indurated, and became 
entirely impermeable to the air." 

To be of diagnostic significance this feeble breathing must be localized 
over one apex, circumscribed, fixed and persistent for some time, and 
uninfluenced by respiratory efforts and cough. It is an indication of 
peribronchial tuberculous infiltration compressing some bronchioles, 
thus creating atelectasis of the alveoli they supply; or of localized 
pleurisy interfering with the respiratory activity of the alveoli in the 
affected area. 

"In massive caseation," says Colonel Bushnell, "the tissues have 
lost their elasticity and, insofar as they are ca seated, do not expand at 
all in inspiration. Ordinary breath sounds are absent in such cases, or 
are present enfeebled in less complete caseations. Ordinarily what is 
heard is a weak and distant bronchial breathing, conducted from the 
deep bronchi and mingled with the coarse rales characteristic of these 
tubes." 

Localized feeble breath sounds are also found over healed tuber- 
culous lesions, or adhesions of the apical pleura following abortive 
tuberculosis. But during the early stage of active phthisis feeble 
breathing is accompanied by constitutional symptoms, such as cough, 
fever, tachycardia, etc., and usually some signs are elicited by percus- 
sion of the same area. As Bezancon 1 has pointed out, in the absence 
of constitutional symptoms, feeble breathing at one apex is a sign of a 
healed tuberculous lesion. 

In advanced phthisis, we very often meet with limited areas of 
feeble or absent breathing, but vigorous cough removes the plug which 
obstructs the entry of air into a bronchus and breath sounds are again 
audible. It is noteworthy and of diagnostic importance that atelec- 
tasis is frequently produced by plugging of a bronchus and the result- 
ing resorption of the air from the alveoli may produce dulness over 
the area supplied by that bronchus, but no breath sounds, no adven- 
titious sounds are heard. Occurring at the base, it is often difficult 
to distinguish it from thickened or adherent pleura, which is also 
characterized by feeble or absent breathing, as is pleural exudate. 

In acute pneumonic phthisis I have repeatedly met feeble breath 
sounds in addition to dulness elicited over the affected lobe of the 
lung; at times there was even absence of all breath murmurs, but 

1 Rev. de la tuberculosc, 1913, x, 1. 



300 AUSCULTATIOX OF THE CHEST IX PHTHISIS 

some moist subcrepitant rales were audible over the same region. 
Similarly, Ave may meet during febrile exacerbations in advanced 
cases, feeble breathing over newly affected areas, which later changes 
into bronchial breathing, etc. 

Rough or Granular Breathing.— This is often found in incipient 
cases. Here again it is the inspiratory murmur that is especially 
affected. It is dry, rough and low-pitched. It should not be con- 
founded with puerile or harsh breathing: Granular breathing may be 
altogether diminished in intensity, or even very faint, while puerile 
breathing is always intense and emphatically pure. On the other hand, 
in granular breathing there is always a suspicion that adventitious 
sounds or noises are superadding the inspiratory murmur. According 
to Sahli, it is a sign of bronchial catarrh; there is either partial imper- 
meability of the bronchi producing unequal respiratory excursions of 
the affected lung area, or else the accompanying noises are derived from 
the secretions causing partial stenosis or irregularity in the lumen. 
When these accompanying noises can be plainly isolated, we call them 
rales, but as they remain indistinct and blended, the vesicular breath- 
ing becomes impure, granular or rough. It is generally heard over the 
supraspinous fossa?, or above and beneath the clavicle. 

Grancher insists that granular breathing is a sure sign of incipient 
phthisis, and Clive Riviere speaks of it as the earliest auscultatory 
sign, while Piery 1 says that it is nothing of the kind, but that it is a 
good sign of a cured lesion and due to cicatrization of a limited area of 
lung tissue, which is undoubtedly a fact. I have seen many patients 
who presented granular breathing at an apex for years without showing 
any of the constitutional symptoms of phthisis. On the other hand, I 
have full confidence in this sign when there are the usual general symp- 
toms of phthisis, because I have repeatedly observed that in the very 
area first presenting feeble or granular breathing there subsequently 
developed typical lesions of phthisis. Of course, one must always bear 
in mind that the absence of constitutional symptoms is an indication 
that the granular breathing is probably due to a cicatrix remaining after 
a tuberculous lesion has healed. 

Interrupted or Cog-wheel Breathing. — The respiration saccadee of 
the French is another anomalous type of breath sounds which has 
for a long time been considered characteristic of early phthisis. The 
inspiratory murmur is not smooth and continuous, as in normal respira- 
tion, but is broken, so that it appears jerky, divided into several more 
or less distinct parts. It differs from rough breathing by the fact that 
each portion of the sound retains its smooth, rustling character. It 
is apparently caused by the obstacles met by the air current while 
entering the alveoli. The breath sounds may be increased or, more 
commonly, decreased in intensity. 

I find cog-wheel respiration only rarely a sign of incipient phthisis 

1 La tuberculose pulmonaite, Paris, 1910, p. 311. 



PROLONGED EXPIRATION 301 

and am inclined to agree with Piery, who says that in the region of 
the apex it is always an indication of pleural adhesions which are 
often the remains of a healed tuberculous lesion. In some cases, 
however, it is met with in the beginning of active phthisis and the 
fact that in the later stages of the disease it can very often be heard 
along the borders of advancing lesions shows that the factors produc- 
ing it may be of the first disturbances of the respiratory murmur in 
the areas of impaired breathing capacity around infiltrated portions 
of the lung. 

Cog-wheel breathing is occasionally heard over chests in nervous 
patients, or such as have pains due to acute pleurisy, or who shiver 
during the examination. But then it is heard all over the chest, while 
in phthisis it is localized over a limited area. 

Prolonged Expiration. — From what has been stated it is evident 
that in the very early stages of phthisis, auscultation reveals only changes 
in the inspiratory murmur, a point which cannot be too strongly empha- 
sized. In older books on the subject we almost always read that 
changes in the expiratory murmur are pathognomonic of early phthisis, 
obviously because in former days incipient phthisis, as we know it 
today, was not recognized. In fact, because even today patients only 
rarely present themselves for examination at the very incipiency of the 
disease, we usually find a prolonged expiratory murmur at the first 
examination. But speaking as one who has had opportunities for exam- 
ination of large numbers of persons who do not even suspect that they 
have any pulmonary trouble, and examining ' the lungs of everyone 
who comes under my care, I find that changes in the inspiratory mur- 
mur, such as feeble breath sounds, rough or cog-wheel breathing, are 
usually found earlier than changes in the expiratory murmur. 

In normal vesicular breathing the expiratory murmur is either 
inaudible or, more commonly, it lasts only one-fifth to one-fourth the 
time of the inspiratory murmur. When it lasts as long as, or longer 
than, the inspiratory murmur it is undoubtedly pathological, though 
not necessarily of tuberculous origin. When audible all over the chest 
it is an indication of bronchitis or pulmonary emphysema, but when 
we find it localized at one apex, its significance as a sign of phthisis 
is to be appreciated. It may be due to sclerosis of a limited portion 
of the lung tissue, as is the case in healed tuberculous lesions. Indeed, 
when it also has a bronchial timber it is pathognomonic of this con- 
dition, and Turban speaks of it as "cicatricial respiration." 

In active early lesions, a prolonged expiratory murmur, localized at 
an apex, is an indication of either catarrh of the smaller bronchioles, 
or pressure on these tubes, in cases in which infiltrations produce 
stenosis. It is therefore usually met with later than. the changes in 
the inspiratory murmur, of which we spoke above. The prolonged 
expiratory murmur is often harsh and rough, and with the advance of 
the disease, it gradually acquires a bronchial character, finally becom- 
ing pure bronchial or tubular breathing. While we may meet it with- 



302 AUSCULTATION OF THE CHEST IN PHTHISIS 

out any adventitious sounds, this is exceptional in my experience. 
On the other hand, it may be feeble and hardly audible and, at times, 
we hear the rales very clearly while the prolonged expiration is so feeble 
that it is only detected after careful listening. 

There is another fact to be borne in mind while evaluating prolonged 
expiration as a sign of early phthisis. Not only may it be the sole 
indication of a healed lesion, as has already been stated, but in the 
right apex it may not be due to tuberculosis at all, especially in young 
adults with thin thoracic walls. In collapse induration it is not uncom- 
mon, while in persons working at dusty trades, such as stone-cutters, 
carpenters, miners, garment-workers, etc., the expiratory murmur at 
the right apex is very often harsh, rough and prolonged. Under the 
circumstances it is of more significance when found in the left apex, 
and in the right side a careful study of the constitutional symptoms 
must be made before attaching any diagnostic value to it. 

Bronchial Breathing. — With the advance of the disease the dis- 
seminated tubercles in the lung conglomerate by growth and form a 
solid circumscribed mass, over which the breath sounds elicited on 
auscultation are more or less characteristic. The vesicular quality 
of the murmur changes by degrees, till it finally becomes high-pitched, 
clear and blowing during both inspiration and expiration, which is 
very prolonged. 

Bronchial breathing is a sign of consolidation of lung tissue: The 
laryngotracheal murmur is transmitted and, according to Sahli, even 
magnified, while passing from the bronchi through consolidated lung 
tissue to the surface. It is thus heard over areas which are dull on 
percussion, particularly over the upper third of the chest anteriorly 
and posteriorly. During the course of chronic phthisis bronchial 
breathing is also caused by many complications which produce com- 
pression of the alveoli with resulting pulmonary atelectasis, as is the 
case in pleural effusions, pneumothorax, hydro thorax, etc. In these 
cases the bronchial breathing is engendered only when the alveoli and, 
at most, the bronchioles are compressed; when the large tubes are also 
obliterated by compression, no breath sounds at all are audible. 

In acute phthisis, bronchial breathing is mainly caused by caseous 
infiltration of the affected areas, and it is harsher, louder and more 
high-pitched, the more compact and extensive the consolidation of 
lung tissue. Bronchial breathing in phthisis is not so loud and reso- 
nating as in pneumonia, and when it is encountered, it is an indication 
of an acute process which is probably progressive and of serious 
prognostic significance. It is therefore found early in the disease in 
acute pneumonic phthisis and during chronic phthisis over the seat of 
new extensions of the process, involving the larger part of a lobe, and 
in the terminal stages, when pneumonia complicates an old lesion and 
carries off the patient. In chronic phthisis, the higher the pitch of 
bronchial breathing, the greater the consolidation of lung tissue may 
be assumed, 



BRONCHOVESICULAR BREATHING 303 

It is a fact to be remembered that in the average case of chronic 
phthisis bronchial breathing does not appear suddenly, but by slow 
degrees. The vesicular murmur is gradually transformed into broncho- 
vesicular, which, with the subsequent consolidation of the process, 
finally becomes purely bronchial. 

Bronchovesicular Breathing. — On rare occasions, we may find 
bronchial breathing with normal resonance over the same area; in fact, 
I have at times met it over areas emitting a tympanitic note on per- 
cussion, which is an indication that even small disseminated tubercles, 
which are incapable of producing dulness, but relax the lung tissue 
and cause tympany, may cause bronchial breathing. 

But usually disseminated tubercles produce bronchovesicular breath- 
ing. We hear a mixture of both vesicular and bronchial sounds over 
the same area, the former originating in the small consolidated areas 
which transmit the laryngotracheal sounds, while the latter come from 
the alveoli of the unaffected lung tissue that surrounds the tubercles. 
It is thus clear that the presence of bronchovesicular breathing is an 
indication of small tubercles scattered within normal lung tissue. 
This is usually preceded by prolonged expiration, which changes by 
degrees into bronchovesicular breathing, and finally into bronchial, 
as has already been shown. 

Sources of Error. — Bronchial and bronchovesicular breathing per se 
are no indications of phthisis. In addition to the many pathological 
conditions which may cause this type of breath sounds, we quite 
often hear it over healthy chests. There are many individuals in 
whom bronchial breathing is heard all over the upper parts of the 
thorax. In the interscapular, right supraspinous and supraclavicular 
spaces it is very common in apparently healthy persons, especially 
during vigorous breathing. This is said by Bandelier and Ropke to 
be found in about one-third of healthy people; it is due to differences 
in the anatomical structure of the two apices. Fetterolf and Norris 1 
have studied these differences in structure in detail, and it appears 
that the breath sounds have better opportunities for transmission 
to the surface on the right side than on the left. In addition, because 
the right lung has three main bronchi, it favors the transmission of 
bronchial breathing more than the left, which has only two. 

Bronchial breathing is very common in these locations and is not 
to be given undue diagnostic significance unless there are other symp- 
toms and signs of phthisis. Individuals with thin thoracic walls are 
more apt to show T this sort of breath sounds, while vigorous breathing 
and dyspnea may accentuate it. To be of diagnostic significance, 
bronchial breathing must be strictly localized over a limited area and 
accompanied by other physical signs, especially dulness at the same spot. 

Another source of error in auscultation is the frequent changes we 
meet in the respiratory sounds in many patients. One day we meet 

1 Am. Jour. Med. Sc, 1912, cxliii, 637 Fetterolf: Arch, Intern. Med., 1909, iii, 13, 



304 AUSCULTATION OF THE CHEST IN PHTHISIS 

at the affected area bronchial breathing, and the next day we are 
surprised by vesicular or feeble breathing, or complete absence of 
breath sounds over the very area where distinct pathological auscul- 
tatory phenomena were audible the day before. Vigorous cough, by 
removing the mucous plug in some tube, may reestablish the original 
sounds. I have seen such changes occurring during an examination 
which lasted less than half an hour. We should therefore beware 
of pronouncing a patient free from changes in the breath sounds 
before making him cough, and reexamining the chest on several 
different days. 

Cavernous and amphoric breathing are discussed later when speak- 
ing of pulmonary excavations and of pneumothorax. 

Adventitious Sounds. — As was already stated while speaking of the 
technic of auscultation, adventitious sounds are to be looked for only 
after ascertaining the character of the breath sounds during each 
phase of the respiratory act. To pass judgment at one time about 
both breath sounds and rales is hazardous and we are liable to over- 
look many important points which are of diagnostic and prognostic 
significance. 

The adventitious sounds audible over phthisical chests in the various 
stages of the disease are manifold. It can be stated that all kinds of 
rales — sonorous, sibilant, crepitant, subcrepitant, gurgling, etc. — are 
met with during the course of the disease, and each variety has some 
significance, indicating various pathological conditions of the lung. 
Paradoxical though it may seem at first sight, yet it is a fact that there 
are no rales which are pathognomonic of phthisis, nor dees their absence 
exclude the disease. Especially is this true of the very incipience of 
active phthisis which, as was already intimated, begins as an infil- 
tration, and not as a catarrh of the bronchi. The neoplastic peri- 
bronchial formations may compress the alveoli; the proliferated 
interstitial tissues may contract and obliterate some air cells, etc., 
but such processes do not produce rales because at this stage the 
bronchi are not flooded with fluid or semifluid secretions which 
could interfere with the entry or exit of air through the bronchioles 
and air cells. Moreover, around an infiltrated area the lung usually 
acts vicariously, and thus veils any alteration in the breath sounds 
that may be created in the diseased focus, and the most we may 
expect is feeble, harsh or cog-wheel breathing, but no rales. 

Rales are only produced when the caseous material softens and 
breaks through the walls of a bronchus: The secretions may irritate 
the bronchial mucous membrane and produce a catarrh which, in its 
turn, produces more secretion which, when set in motion by the 
passing air stream, engenders rales. This is a fact that I have had 
many opportunities to observe in patients who at first showed only 
alterations in the breath sounds, especially weak vesicular murmur 
or cog-wheel breathing, etc., but no rales, in spite of all constitutional 
symptoms of phthisis which went on its course, and only later adven- 



CREPITATION 305 

titious sounds made their appearance. In such cases a diagnosis of 
phthisis must be made without finding any rales. In fact, I have met 
with acute cases in which a whole lobe was infiltrated in a compara- 
tively short time; percussion showed distinct dulness, auscultation 
disclosed prolonged expiration, even bronchial breathing, but no 
rales at all were audible. It will therefore bear repetition that waiting 
for rales, as some text-boohs teach, may be worse than ivaiting for 
tubercle bacilli in the sputum before making a diagnosis. 

It is worthy of mention that while rales are an indication that the 
tuberculous process is beyond incipiency, they do not invariably 
point toward an unfavorable prognosis. "Rales constitute the auscul- 
tatory eA'idence of inflammatory reaction to the poisons of tubercle/' 
says Colonel Bushnell. "They are the best evidence that the lesion is 
resisting its foe. Rales are absent in the obsolete or arrested lesion — 
the body does not need to fight. They are present in the stage of reac- 
tion — the body is fighting — whether successfully or not is to be deter- 
mined in part by the number and quality of the rales, in part, by other 
considerations. They may be absent again when the body can no longer 
fight — when the power to react has been lost. Nothing could be more 
erroneous than to draw favorable conclusions from the diminution or 
the disappearance of rales in the very advanced case." 

Crepitation. — With the onset of softening, the crepitant and, at 
times, the subcrepitant rale can be discovered at the affected area. 
The former is audible exclusively during inspiration, or only at its 
end, and has been compared to the sound produced by rolling one's 
hair between the fingers near the ear. All agree that this rale is not 
caused by the motion of fluid secretions in the small bronchi and air 
cells; nor by the explosion of air bubbles in the bronchi, as was for- 
merly supposed. The consensus of opinion appears to be that it is 
caused by the inspiratory stream of air tearing apart sticky surfaces 
of the approximated alveolar walls, though many hold that the crepi- 
tant rale is altogether a friction sound produced by rubbing of the 
two pleural sheets covered with tubercles, as was first suggested by 
Learning, 1 I am inclined to consider them purely atelectatic rales, 
analogous to those met with over the margins of healthy lungs in per- 
sons who breathe superficially, and which are often mistaken for 
crepitations. On the other hand, considering that apical tuberculous 
pleurisy is quite frequent (see page 426), these adventitious sounds 
are not infrequently due to frictions. The differentiation between 
pleural and parenchymatous lesions is discussed elsewhere. 

Crepitant rales are usually audible during quiet breathing, and 
provoked by vigorous coughing and breathing. Moreover, they 
disappear after several strong efforts at deep breathing, which would 
not be the case if they were friction sounds. They may be found 
early in the morning, and missed throughout the day, and I have 

1 Diseases of the Heart and Lungs, New York, 1884. 
20 



306 AUSCULTATION OF THE CHEST IN PHTHISIS 

seen them appear and disappear within half an hour during an exami- 
nation. At times, they are heard at a very early stage of the disease 
as quite numerous cracklings over the affected area, while in other 
cases but few are audible, and they are spoken of as "dry crackles/' 
the craquements sees of French authors. 

Crepitant rales are not by any means pathognomonic of phthisis, for 
reasons already stated, but when audible over an apex showing contrac- 
tion of Kronig's resonant areas, or impaired resonance in a person show- 
ing some of the important constitutional symptoms of phthisis, they are 
to be taken seriously. However, in order to evaluate them properly, 
we must carefully study them with particular reference as to per- 
manence during several examinations on different days and that cough 
does not entirely remove them. I attach greater significance to c epi- 
tant rales when heard over the supraspinous fossa, the alarm zone (see 
p. 336) , than when heard anteriorly above or immediately below the 
clavicle, because in the latter location they are as often spurious as 
real. We are often able to follow them up to the stage when they 
become moist — subcrepitant — and finally we find that signs of exca- 
vation appear at the same spot. 

During the course of phthisis, the crepitant rale is heard quite 
often around the seat of the main lesion, indicating that the process 
is extending, and over pneumonic areas so often caused by acute 
exacerbations. In unilateral cases, in which the other side is second- 
arily implicated, we may find that in the latter the first audible adven- 
titious sounds are crepitations, and these secondary lesions are worthy 
of study by those who want to be able to recognize and evaluate these 
adventitious sounds. In fact, while teaching tuberculosis to students, 
advanced cases are better for this reason than early cases in which the 
diagnosis is often doubtful. 

Moist Rales. — With the advances of the process, softening sets in 
and the disintegrated tubercles are eliminated from the focus through 
the bronchi, to be finally expectorated. These fluid and semifluid 
secretions, while remaining at the site of the lesion and in the bronchi, 
are often obstacles to the entry and exit of the air current and thus 
produce rales. In mild cases with but little secretion, we meet with the 
high-pitched subcrepitant rales produced in the small bronchi. When 
softening and liquefaction proceed and the secretions become more 
and more copious, the size of the rales increases and we hear medium, 
large and coarse bubbling rales and gurgles. 

The difference in the size of the rales apparently depends on the 
difference in the size of the bronchi in which they originate — large 
bronchi can hold larger masses of fluid and mucous secretion, and in 
smaller tubes less secretions are moved, while in excavations the 
mass of secretion may be very large and, as a result, we get gurgles. 
The larger rales are more intense and louder, though of a lower pitch 
than the smaller, but the latter are usually more numerous, evidently 
because there are more small bronchi than large ones. Rales are 



SIBILANT AND SONOROUS RALES 307 

greater in number, and more eonsonating, when originating super- 
ficially, while those engendered deeply in the lung may not be heard 
at all. At times, we can hear rales in central lesions by placing the 
bell of the stethoscope in front of the patient's mouth, while all over 
the chest nothing is audible. 

It must be emphasized that no rales per se are pathognomonic of 
phthisis, because we hear more adventitious sounds in many other 
conditions, notably bronchitis and bronchiectasis, than in the average 
case of chronic phthisis. To be of significance, the rales must be 
strictly localized over a limited area and persistent. It can be stated 
that, excepting in far-advanced cases, or the rare cases of chronic 
bronchitis complicating tuberculosis, and some forms of fibroid phthisis, 
the larger the area oxer which moist rales are heard, especially bilaterally, 
the less the likelihood of their being of tuberculous origin; the higher up 
in the chest they are exclusively audible, the more likely that they spell 
phthisis; and, when heard exclusively at the bases or- over the lower lobes, 
the chances that they are tuberculous are rather scanty. Large bubbling 
rales, when heard over areas where there are no large bronchi, as in the 
upper third of the chest, are of greater significance than when heard 
over areas beneath which large bronchi are located. The latter may be 
caused by bronchitis or bronchiectasis. When large bubbling rales 
are heard near the bell of the stethoscope, they are indications of 
phthisical excavation, because there are no large bronchi near the sur- 
face of the lung. 

Sibilant and Sonorous Rales.— These are very often heard over 
tuberculous foci. In many incipient cases, especially in those with 
stationary or healing lesions, whistling and snoring rales are not uncom- 
monly localized over one apex, especially posteriorly. When not 
accompanied by crackles we may take them as an indication of healing, 
and that they are caused by the compression of the bronchioles by 
fibrous tissue which forms during the process of repair. Similarly, 
we hear sibilant and sonorous rales as the only reminders of an old 
and cured tuberculous process. In senile phthisis, sibilant and sono- 
rous rales are often the only adventitious sounds. 

The asthmatic forms of phthisis, as well as those accompanied by, 
or implanted on, diffuse bronchitis and pulmonary emphysema, espe- 
cially in fibroid phthisis, often manifest themselves by sibilant and 
musical rales heard during inspiration and expiration. We hear all 
kinds of musical notes, snoring, cooing, whistling, grunting, groan- 
ing, whining, etc. They may be heard alone while the respiratory 
murmur is feeble or inaudible, and then they may also be accompanied 
by all kinds of moist rales. When audible all over both sides of the 
chest, the diagnosis of tuberculosis may not be an easy task and dif- 
ferentiation from chronic bronchitis, pulmonary -emphysema, asthma, 
etc., can only be made after considering the signs revealed by percus- 
sion, as well as by the constitutional symptoms, and in some cases 
only the microscopic findings in the sputum can decide. When these 



308 AUSCULTATION OF THE CHEST IN PHTHISIS 

sonorous and sibilant rales are heard unilaterally in the upper part of 
the chest they are easily diagnosed, as a rule. 

Provoked Rales. — In many cases of early phthisis, and also at times 
in those with advanced disease, no adventitious sounds are heard on 
ordinary, or even forced, breathing; but more or less vigorous cough 
brings out an explosion of rales. Some writers have spoken of these as 
" latent rales," which is an incongruous term. Bray 1 found that in 75 
per cent, of cases of early phthisis, and in 30 per cent, of those with 
moderately advanced disease, rales could be provoked by cough. We 
should not pronounce a patient free from adventitious sounds unless 
cough has been impotent in provoking them. 

The mechanism of production of these rales has been a disputed sub- 
ject. Some have suggested that they are produced by the separation of 
the collapsed walls of the alveoli and smaller bronchioles in and around 
the diseased focus. Bray is not satisfied with this explanation and 
offers the following : Toward the end of expiration the glottis is volun- 
tarily closed and the intrapulmonary pressure is increased by powerful 
contraction of the expiratory muscles. This sudden increase in the 
intrapulmonary pressure separates the collapsed walls of the bron- 
chioles and alveoli and the atelectatic area. Once the patency of these 
structures is established, the rale is produced by means of the cough, 
which sets into vibration the pathologic secretions contained within the 
bronchioles and alveoli. 

All kinds of rales maybe provoked by cough. In early cases, some dry 
crackles may thus be brought out, or small, moist rales, and, at times, 
even showers of explosive rales may be provoked in cases in which no 
adventitious sounds were audible. In advanced cases large, moist, 
consonating rales may be brought out by cough when the bronchus 
leading to the cavity has been plugged, but the cough clears the 
passage, and permits the secretions to move with the air current. 
In others, sibilant rales are thus provoked. The rales are usually heard 
during inspiration, but at times during both phases of the respiratory 
act. 

Of course, no attempt should be made to provoke rales during or 
after a pulmonary hemorrhage, for obvious reasons. 

Friction Sounds. — These are very often heard over phthisical 
chests. Over the apex they are heard best anteriorly above and 
beneath the clavicle, but here they are usually not very distinct because 
of the limitation of the motion of the lung in that region. Yet we 
sometimes perceive some grating. This is usually very difficult to 
differentiate from crepitation — all the criteria given in text-books 
are futile in some cases. At the lower parts of the thorax friction 
sounds are more common, especially in the axillary region. On rare 
occasions a pleuropericardial rub is heard not only during the respira- 
tory phases, but also synchronous with the heart-beat. It is an 

1 Jour. Am. Med. Assn., 1916, lxvi, 788. 



SPURIOUS RALES 309 

indication of dry pleurisy of the lingula or other parts of the pleura 
in contact with the pericardium. 

We distinguish friction sounds from rales by the fact that the 
former are heard superficially, right near the bell of the stethoscope; 
often they are increased by pressure of the stethoscope; they are 
uninfluenced by cough which usually increases the intensity of rales 
or entirely removes them; , they are annulled when the breath is held. 
But the most important difference is that crepitant rales are heard 
during inspiration only, while friction sounds are audible during both 
phases of the respiratory act. However, in many cases it is quite 
difficult to state positively whether the adventitious sounds under 
consideration are of pulmonary or pleuritic origin. When found over 
an extensive area, especially posteriorly, or in the axillary region, 
frictions may be diagnosed by assuming that rales over such a large 
area would represent a very extensive pulmonary lesion with severe 
constitutional symptoms, while pleurisy may persist for years without 
impairing the general condition of the patient very much. 

Spurious Rales. — Rales of extrapulmonary origin are occasionally 
heard while auscultating chests, and attributed to tuberculous 'changes 
in the lungs. In persons suffering nasal obstruction we may hear 
various sounds resembling rales which disappear when the patient is 
made to breathe through the mouth. A frequent cause of extra- 
pulmonary rales is the falling back of the tongue when the patient 
makes strong efforts to breathe deeply, also after vigorous coughing 
the patient swallows and we believe that we hear rales in the chest. 

Other spurious rales, described by Peretz 1 and William Ewart 2 in 
England, Colonel G. E. Bushnell 3 and Hawes 4 in this country, are 
caused by muscular contractions, especially the trapezius, and on rais- 
ing and lowering the shoulders and arms. In persons who lift their 
shoulders when asked to breathe deeply these " rales" are often quite 
audible. French authors speak of them as eraquements et frottements 
sous scapulaires, which can be heard very often over the upper part of 
the chest posteriorly. These muscle sounds were a potential source of 
error in 9.2 per cent, of 250 cases examined by Hawes, while joint sounds 
were found in 22 per cent, of cases. 

J. T. King, 5 examining over 22,000 soldiers for tuberculosis in the 
United States Army, looked especially for these joint sounds. He kept 
notes of 819 men as to the incidence of spurious rales in the upper part 
of the chest. In 33 cases, or 4 per cent., crepitations were audible at, 
or near, one or more joints. Most of these sounds emanated from the 
scapulae, the costosternal and sternoclavicular articulations, and from 
the joints at the shoulder anteriorly. In 23 instances, certain crackles, 
usually rather loud and explosive, were heard for one or a few respir- 

1 British Med. Jour., 1896, i, 82. 2 Ibid., 1912, i, 771. 

3 Medical Record, 1912, lxxxi, 101; lxxxii, 1109. 

4 Boston Med. arid Surg. Jour., 1914, clxx, 153. 

5 Military Surgeon, 1918, xlii, 60. 



310 AUSCULTATION OF THE CHEST IN PHTHISIS 

ations over the apices, disappearing promptly during continued breath- 
ing. In 17 cases, or 2.07 per cent., there were found persistent apical 
clicks or crackles, of the type which had often proved confusing. Dur- 
ing the recent selective draft for the United States Army, several 
patients who consulted me after being rejected because of tuberculosis, 
Were found to have these spurious rales in the chest. Some could not 
be convinced that they were not tuberculous, because many physicians 
told them that they have "rales" in the chest. 

The so-called atelectatic and marginal rales are even more often 
found and must be guarded against. They are mostly heard over 
the anterior and lower margins of the lungs and are probably caused 
by the unfolding of collapsed alveoli in individuals who breathe 
superficially and also by the peeling off of the diaphragm from the 
chest wall as the lung descends into the complemental space. Richard 
C. Cabot 1 found them in 61 per cent, of normal chests and speaks of 
them as crepitant and subcrepitant varieties. They usually disappear 
after a few breaths, but at times they persist indefinitely. 

Bushnell also described sounds originating in the sternum and its 
articulations, heard particularly at the second costal cartilage, which 
may lead to error, and I have been able to verify his findings in a 
large number of healthy persons, especially in muscular men. In some 
cases they resemble crepitation and occasionally even medium-sized 
moist rales and clicks, like the adventitious sounds of early phthisis. 
They can usually be differentiated from pulmonary rales by the fact 
that they are localized and heard loudest over the sternum and its 
articulations, but in doubtful cases, especially those showing a short 
note at one apex, they may lead to error. 

It is usually easy to differentiate these sounds from intrapulmonary 
rales, but at times they may prove confusing to the most expert. The 
crackles heard over the apex, originating in the neck muscles, are 
identified by their loud, explosive character, and by the fact that they 
are not influenced by cough. Moving of the head to one side or another 
may be effective in supressing them. Bushnell and King suggest the 
following criteria for the identification of the joint crepitations: They 
are of a groaning or grating character and disappear when the patient 
folds his arms and grasps the opposite shoulder with his hands; by 
having him, while standing, bend the trunk forward to a horizontal 
position and allow the arms to hang limply downward; by having 
him grasp an object at a level about as high as he can reach, and exert 
enough weight on his arms to fix the scapulae apart. Crepitations from 
the lateral sternal articulations may often be eliminated by having the 
patient throw his shoulders as far back as possible. 

Voice Sounds. — Bronchophony adds little if anything to the infor- 
mation we gain by percussion and auscultation. It is generally heard 
over areas which are dull on percussion and show bronchial breathing. 

1 Physical Diagnosis, New York, 1909, p. 163. 



VOICE SOUNDS 311 

Moreover, it is necessary that the pulmonary consolidation should 
he superficial in order to produce distinct bronchophony while the 
breath sounds may be altered with moderately deep lesions. Of course, 
loud transmission of the voice suggests dense pulmonary consolidation 
through which a bronchus is passing, while decreased voice sounds 
indicate pleural effusions, thickened pleura, emphysema, or merely thick 
chest walls; in short, anything that diminishes the conductivity of the 
lung, and intervenes between the large bronchi and the surface. Even 
a plugged bronchus may diminish or abolish the voice sounds, which 
reappear after vigorous cough. 

Bronchophony is very loud in persons with thin chest walls, or who 
have a deep voice; and, in general, in the interscapular space, especially 
in the right side, for obvious reasons. The various distinctions of 
bronchophony, pectoriloquy, etc., have no significance in the diagnosis 
of phthisis. 

Whispered Voice. — Of greater importance is the auscultation of the 
whispered voice. In this it is really not the voice that is transmitted 
but the breath sounds, to which are added different reverberations 
from the oral, pharyngeal, and nasal cavities. My experience is in 
agreement with that of Sewall to the effect that in auscultation of the 
whispered voice we have an unrivalled means for the detection of 
minute changes in the pulmonary tissue. I have been able to outline 
consolidations and excavations of lung tissue by carefully studying 
the whispered voice, and other methods of diagnosis have merely 
confirmed the findings. Inasmuch as it is very easy to acquire, it 
ought to be more generally adapted in the routine study of phthisis 
in all its stages. 

We must, however, remember that the chest walls are also vibrating 
when the person whispers and especially when he talks, as has been 
shown by Sewall. 1 He suggests that the mural vibrations should 
be damped by pressure with the stethoscope, and thus only the visceral 
vibrations will be brought to the auscultating ear. He shows that, in 
general, it may be said that with the intense congestion of the lungs or 
such tissue changes as occur in early phthisis, the voice takes on a 
more or less amphoric or tracheal character and it tends to become more 
distinct, prolonged, raised in pitch and nearer the ear, with pressure 
of the stethoscope on the surface of the chest. When the patient 
counts "one, two, three," there is a tendency for the voice to linger 
with a bleating echo which is exaggerated by stethoscope pressure. 
This has often helped me in doubtful cases in which both percussion 
and auscultation were absolutely inadequate to justify a final opinion. 

Whispered pectoriloquy is also of immense value in patients with 
laryngeal involvement, or who have pleural pains and cannot breathe 
deeply, and especially in patients soon after a hemorrhage when we 
should hestitate in going through all the diagnostic maneuvers which 

1 Jour. Am. Med. Assn , 1913, lx, 2027; Sewall and Childs: Aich. Intern. Med., 1912, 
x, 45. 



312 AUSCULTATION OF THE CHEST IN PHTHISIS 

may cause the bleeding to recur. Whispered pectoriloquy, bron- 
chophony and auscultation during ordinary breathing can give us 
sufficient information to form an opinion on the extent of the lesion. 

Over healthy lungs the whispered voice is audible in the upper third 
of the chest, especially on the right side, while in the lower parts it 
is hardly, or not at all, audible. An increase in the intensity is an 
indication of better sound conduction — consolidation or compression 
of pulmonary parenchyma, or even congestion, as has already been 
mentioned. It is therefore an early sign of phthisis. It must, how- 
ever, be borne in mind that it is heard over healed lesions and there- 
fore is not to be taken for a sign of activity of the process without 
confirmation by constitutional symptoms. 

Over air-filled cavities, pulmonary or pleural, we hear what Kuthy 1 
calls "amphorophony" — the transmission of the whispered voice with 
an amphoric or metallic echo. It is an indication that the cavity or 
the pneumothorax has smooth walls. In cases with cavities we can at 
times make out the extent of the excavation by auscultation of the 
whispered voice as well as by any other method. 

1 Die Prognosenstellung bei der Lungentuberkulose, Beilin. 1914, p. 302. 



CHAPTER XVII. 
SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS. 

Soon after the introduction of the .r-rays, great hopes were enter- 
tained that finally a means of visualizing the condition of the thoracic 
viscera and detecting any changes in the lungs, bronchi, and pleura 
had been obtained. But after several years' experience it was found 
that in tuberculosis skiagraphy has its limitations, just as other diag- 
nostic methods. On the one hand, it does not disclose infiltrations, 
the very early changes in phthisis ; on the other hand, because it clearly 
shows caseated and calcified foci, revealing airless areas of lung tissue, 
it helps in establishing an anatomical diagnosis. Whether the changes 
discovered are tuberculous in character, and whether the lesion is 
active, must be ascertained by other clinical methods. For this reason, 
skiagraphy, while a very important aid in diagnosis, cannot be relied 
on to the exclusion of other methods. It does not disclose catarrhal 
conditions nor does it reveal infiltrations. 

When properly used, skiagraphy helps materially in discovering 
certain changes in the intrathoracic viscera which formerly escaped 
notice during the life of the patient. Especially is this true of deep- 
seated lesions, pleural adhesions, enlarged bronchial glands, localized 
and interlobar effusions, localized pneumothorax, small cavities in 
the lungs, the motion of the diaphragm, abscess and gangrene of the 
lung, etc. 

The condition of the lung, and the changes at the site of the lesion 
in the average case of early phthisis can be made out easily by auscul- 
tation and percussion. The former even gives important indications 
as to the activity of the process discovered. But the .r-rays complete 
the examination, and often reveal deeper-lying changes in the chest 
which otherwise escape detection. Moreover, the practise of artificial 
pneumothorax, which has lately been applied with such striking success 
in proper cases, could not have gained general acceptance but for 
skiagraphy. 

The technic of .T-ray examination, especially the comparative value 
of the various apparatus employed, will not be discussed here. This 
is the province of specially trained technicians. But every physician 
handling tuberculous cases should be able to read an .r-ray plate and 
not depend entirely on the specialist radiographer for interpretation 
of the findings. When interpreted in connection with the clinical symp- 
toms, with which the physician alone is acquainted, the x-rays yield the 
best results. 



314 



SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS 



Appearance of the Normal Chest. — The appearance in the normal 
chest should be known before attempting to decipher pathological 
changes. It is, however, a fact that a normal chest, showing no signs 
suggestive of pathological conditions, is exceedingly rare. I have not 
yet seen one. Plate X, page 320, shows a plate from a chest of a man 
apparently free from pulmonary -disease. 

While passing through the thorax, the rays are obstructed by the 
various tissues, according to their density, volume and constituent 
elements, and the result is that the denser tissues cast shadows on the 
screen or plate. The densest shadows seen are that of the heart and 
great vessels in the middle and to the left, and the diaphragm beneath. 




Fig. 60. — Structures making up the hilus shadow: R, second rib; W, second thoracic 
ve tebra; V, arch of azygos vein; B, bronchus; L, bronchial lymphatic glands; A, aorta; 
P, pulmonary artery; O, esophagus; D, thoracic duct. (Doyen.) 



Because it permits the rays to pass with less resistance than any other 
organ in the chest, the lung gives a dark image on the negative; the 
heart, the large vessels, the diaphragm and the liver, because of their 
density and blood content, obstruct the rays and produce light areas 
on the plate. The most translucent parts of the healthy viscera are 
the healthy lungs, but when they are collapsed by air in the pleura, as 
in pneumothorax, the space is even brighter. In healthy persons, when 
the patient takes a deep inspiration, the lungs brighten up. But the 
brightness of the lung tissue is not absolute. There is seen a delicate, 
at times even a more or less coarse, arborization, as of a network, 
passing from the roots of the lung to the periphery. At the roots it 



TUE II I US SHADOW 315 

Is caused by the greater density of the tissues, but in most persons 
also by the deposition of carbon particles, which may be found in 
nearly every individual over fifteen years of age. When the shadow 
at that point is abnormally accentuated, it may be an indication of 
enlargement or calcification of the glands, and in children it points 
to tuberculous tracheobronchial adenopathy. Often we note in this 
region small, sharply defined, oval opacities which represent optical 
sections of bloodvessels. 

It is, hcwever, difficult or impossible to evaluate every shadow or 
opacity because by their passage through the chest the rays are 
obstructed by the various parts constituting the viscera, thus pro- 
ducing superimposed shadows. Carefully prepared stereoscopic pic- 
tures may enable us to distinguish these superimposed shadows in 
perspective, but they are after all not much superior to a good skia- 
gram taken by instantaneous exposure. The excellent studies on 
the subject made in this country by Dunham, Boardman, Wolman, 1 
Bibb and Gilliland, 2 and others have contributed considerably to our 
knowledge in this direction. 

The Hilus Shadow. — The shadows seen at both sides of the heart 
are very frequently a source of confusion in diagnosis. As will be seen 
from Fig. 60, they are due to the density of the tissues composing the 
bronchi and the large vessels, which are seen either in transverse or in 
optical section, combined with the opacities produced by the regional 
lymphatic glands and connective tissue, none of which can be differ- 
entiated on the screen or plate. While in some cases circumscribed 
opacities or spots represent calcified glands or nodules, in others they 
are produced by deposits of dust in the peribronchial lymphatic tissues 
which are very frequent in adults, and even in children in cities they 
are not uncommon. But in many cases simple engorgement of these 
tissues with blood is apt to give a shadow in that region. In fact, 
during attacks of measles or whooping-cough the glands in the chest 
have been found visible in skiagraphic plates, and the same is often 
the case in acute affections of the respiratory tract in children or 
adults. 

It is thus clear that many conditions other than tuberculosis of 
the tracheobronchial glands may cause shadows or opacities in the 
hilus region. Moreover, even when these opacities represent anthra- 
cotic or calcareous glands, the skiagram alone gives us no clue as to 
the activity of the process, which is after all the main problem in 
clinical diagnosis. In children it is hazardous to diagnosticate tracheo- 
bronchial adenopathy because of these opacities when the clinical 
picture is not in agreement. 

To the right side of the heart the hilus shadow is more extensive 
than to the left because in the latter location the heart shadow obscures 
the hilus structures. In many cases we see strands passing from the 

1 Bull. Johns Hopkins Hosp., 1911, xxii, 229. 

2 Arch. Int. Med., 1915, xv, 588. 



•1 






316 SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS 

hilus to the periphery or the diaphragm. It is the consensus of opinion 
that they are produced by bloodvessels and occasionally by bronchi 
which at times appear in optical section. 

Fluoroscopy. — In the vast majority of cases of tuberculosis, and 
in suspects, a fluoroscopic examination is sufficient for diagnostic pur- 
poses; in the few cases in which a plate is desirable, fluoroscopy is not 
to be neglected, because it gives us information which the plate does 
not. Fluoroscopy shows the motion of the parietes of the chest, of 
the diaphragm, and of the pulmonary apices, etc. The room in which 
fluoroscopy is done must be totally dark and inasmuch as this is very 
difficult to attain in the average physician's office, it is best done in 
the evening. 

The following points are to be looked for on the fluoroscopic screen 
when examining a chest : The ribs ; the median shadow; the diaphragm ; 
the hilus shadow; the space above the clavicle is to be carefully studied. 

In healthy and well-formed individuals the ribs are seen sym- 
metrically placed on both sides, moving with each respiratory act. 
Unilateral limitation of motion of the ribs is suggestive of unilateral 
disease, and phthisis is to be thought of in this connection. When we 
find the ribs on both sides unduly horizontal we should look for pul- 
monary emphysema; when the horizontal setting is unilateral, while 
the lung markings are absent, pneumothorax is to be suspected. Nor- 
mally, especially in young subjects, the costal cartilages are not dis- 
tinctly visible on the screen. The ribs are sharply cut off (see Fig. 2, 
Plate X) . In older persons they are usually visible, owing to ossifica- 
tion which takes place with advancing age. In tuberculous patients 
ossification of the costal cartilages, especially the first (Fig. 1, Plate 
XIV), is very frequently seen on the skiagram. As was already stated, 
Freund considers this a predisposing factor to phthisis because of the 
stenosis of the upper aperture of the thorax which it is apt to cause. 
In some cases of phthisis all the costal cartilages are calcified, and when 
looking at a patient's chest in the fluoroscope, this point should not be 
neglected. But it must be mentioned that it is not an infallible sign 
of phthisis. It may be found in persons who are not sick, while I have 
repeatedly observed cases of advanced phthisis in which the costal 
cartilages were hardly visible. 

Within the thoracic cavity the deep shadow representing the medias- 
tinal organs, the heart, aorta, pulmonary artery, vena cava?, as well 
as the sternum and the vertebral column, is to be carefully examined. 
It is triangular in shape, the base extending markedly to the left of the 
sternum. The middle third of its right border represents the superior 
vena cava: when bulging out, the lower third represents the right 
auricle. The left border is made up of three successive convexities: 
The first is produced by the arch of the aorta; the middle, the pul- 
monary artery; while the lower is the left ventricle of the heart. All 
or any of these convexities are seen, in many cases, to throb rhythmi- 
cally; at times the alternation between the beats of the ventricle and 



FLUOROSCOPY 317 

those of the pulmonary artery may be seen very clearly. In phthisis 
the heart is, as a rule, smaller than normal. 

The hilus shadow, on both sides of the median shadow, should be 
carefully studied. It is best seen in the right side because in the left 
it is in part covered by the heart. As was already stated, its significance 
is very frequently overestimated by radiologists. It is now the con- 
sensus of opinion that in healthy individuals it represents primarily 
the vascular organs of that region, while the bronchi apparently play 
only an accessory part. When the thoracic glands are enlarged or 
calcified, the bilus shadow appears larger and more accentuated. This 
point is discussed elsewhere in detail. 

The lungs are seen within the thoracic cage as two triangular bright 
fields ; the upper part is separated from the rest by the shadow of the 
clavicle above which the lung apex can be inspected. The base is 
delimited by the diaphragm, which moves with each respiratory act, 
being raised during expiration and lowered during inspiration. 

The apices are carefully inspected, and the translucency of the 
lungs in these regions inquired into. Theoretically, it should be of 
equal intensity on both sides, but such perfection is only rarely en- 
countered, even in healthy persons. Usually, owing to thickness of 
the muscles, scoliosis, etc., one side is somewhat darker. But this is 
best studied on the skiagraphic plate. With the fluoroscope we look 
for the "cough phenomenon," first described by Kreuzfuchs. 1 This 
author noted that in healthy individuals the translucency of the 
apices varies according to various conditions, especially the form of the 
chest. Deep respiratory efforts may clear up any shadow in healthy 
lungs. During cough the apices brighten up even when they are other- 
wise quite dark, excepting when there is diseased tissue in that region 
and the affected apex remains dark even during cough. 

But this is not a very reliable sign. Jordan 2 says: "Failure of the 
apex to light up is difficult to make out with certainty; there are 
endless fallacies due to the position of the .T-ray tube, the thickness 
of the pectoral muscles of the patient, the ' lie' of the ribs and clavicle, 
etc., and at best it is almost impossible to reproduce this 'failure' on 
a photographic plate with any certainty. I am quite sure that we 
should diagnose pulmonary tuberculosis in a large number of healthy 
subjects if we are to rely on this sign." 

This view is shared by many, but it appears that Jordan is mistaken 
in his statement to the effect that the cough phenomenon cannot be 
reproduced on a skiagraphic plate. As will be noted on Plate XII, 
F. Hoist 3 has succeeded in reproducing this phenomenon very clearly. 
Moreover, this author has also shown that during cough there is an 
alteration in the lateral limits of the pulmonary apices, they become 
wider while the trachea becomes narrower, sometimes as much as 1 cm. 

1 Munchen. med. Wchnschr., 1912, lix, 80. 

2 Lancet, 1914, i, 963. 

3 Munchen. med. Wchnschr., 1912, lix, 1659. 



'!| 



318 SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS 

In normal individuals this phenomenon is observed on both sides to 
the same degree, while in case one apex is altered by tuberculous 
changes, it fails to brighten up, and remains narrow and darker during 
cough. Of course, this phenomenon is best studied on the screen, 
and only exceptionally may it be reproduced on a skiagraphic plate. 
We must, however, guard against mistaking the apparent changes 
in the brightness of the apices during cough caused by the separation 
of the ribs and widening of the intercostal spaces. It has been of 
immense service to me in many cases. 

With the aid of fluoroscopy we also ascertain the size and position 
of the heart. In phthisis this organ is, as a rule, smaller than normal. 
In fact, when I find a large heart in a dubious case I hesitate before 
making a diagnosis of phthisis. In phthisis it is also very often ver- 
tical; it may be "hanging," cardioptosis, and in more advanced cases 
frequently displaced toward the affected side. 

After the apices, the diaphragm should claim our attention. The 
mobility of this muscle has been found defective on the affected side 
in many cases of phthisis; according to F. H. Williams, 1 in the very 
incipient stage. The motion of one-half of the diaphragm may not 
only be delayed when there is a pulmonary lesion, but it is at times 
seen to be "jerky," or " stammering," as Harold Mowat says. In 
some healthy persons the mobility of the diaphragm is very limited, 
while in most the breathing excursion is from three-fourths to one 
inch, and during forced respiration it may even move more than two 
inches, the left half of the muscle more than the right. When both 
sides are stationary it may indicate emphysema, or nothing at all, 
but when one side moves while the other is immobile or its excursion 
is relatively limited, we should suspect tuberculosis. Various explana- 
tions have been given for this phenomenon. Some have attributed it 
to diminished power of retraction of the lung, others to implication 
of the terminal branches of the vagus, or of the phrenic nerve in apical 
pleural thickenings, etc. In advanced cases limitation of motion may 
be due to pleural adhesions. It must, however, be emphasized that in 
itself defective movement of the diaphragm may be found in healthy 
individuals. If unilateral it may be due to paresis of that muscle, or to 
an old basal pleurisy producing adhesions which hinder its excursion. 
In persons with big abdomens, the breathing is usually purely thoracic, 
and the diaphragm is immobile. 

Extensive experience has shown limitation of motion on the affected 
side of the diaphragm in only a few cases of incipient phthisis. Indeed, 
we often see advanced cases in which both sides of the diaphragm 
are freely and equally mobile. On the other hand, limitation is found 
in non-tuberculous cases owing to adhseions remaining after previous 
attacks of pleurisy. In advanced cases this phenomenon has to be 
considered in connection with the feasibility of artificial pneumothorax, 
but, as will be shown later on, it is not absolutely reliable. 

* Am. Jour. Med. Sc,, 1897, cxiv, 655. 



RADIOGRAPHY 319 

At the outer extremities of the diaphragm are the costodiaphragmatic 
sinuses. They should be examined carefully in every case, and both 
sides should be compared. The lower angle of the sinus should be 
long and sharp; during inspiration it enlarges and brightens up; it 
contracts and loses its brilliancy to some degree during expiration. 
Any diminution in its size, or obtuseness of its apex, or its complete 
obliteration, indicates a pathological process of the pleura or lung. 
The two sides should then be compared, but it must be borne in mind 
that in the right side the liver makes it somewhat smaller, while in 
the left side the air bubble of the stomach may alter it to some degree. 
The angle formed by the heart and the liver, the cardiohepatic angle, 
often appears obtuse or obliterated in tuberculosis, especially pleurisy 
or thickened pleura. The dome of the diaphragm is also changed by 
a thickened pleura; it is no more smooth, but shows marked elevation 
of the curve during inspiration; in others, we note a series of small 
irregularities in the contour; in still others, bands of connective tissue 
are seen passing from the diaphragm to the lung. 

Radiography. — Of great value in all stages of phthisis, especially 
in dubious early cases, and in those in which a permanent record is 
desired, is radiography. When properly taken and developed, the plate 
may be studied at leisure and slight alterations, which are not visible 
on the fluoroscopic screen, may be detected. 

In evaluating the skiagraphic findings we must bear in mind the 
following points: Small infiltrations do not show any definite and 
clear-cut signs on the plate; at any rate, the shadow they cast is not 
pathognomonic. Cohn 1 inserted tuberculous tissue into healthy lungs 
of cadavers, of which he took radiograms and found that 1 c.c. of 
diseased tissue is not visible on the plate. Ziegler and Krause 2 have 
investigated the problem and found that pieces of tissue less bulky 
than 4 c.c. are not visible on the skiagram, and that, on the whole, 
small areas of infiltration are only visible when the}' are located near 
the surface of the lung. In other words, small infiltrations, when 
centrally located, are screened by normal pulmonary tissue, and may 
escape detection. When the lesion has caseated it casts a more or less 
dense shadoiv. But then the case is no more incipient. 

In many cases we find that the affected apex is darker than its mate 
on the opposite side. In others, the affected area has the appearance 
of "ground glass." But even this does not invariably imply an active 
lesion. Indeed, it may be put down as a general rule that, in suspicious 
cases showing no constitutional symptoms, the darker the apex, the 
less likely the probability of its being a sign of active incipient tuber- 
culosis. It may be revealing an old and healed lesion. I have been 
impressed with the following fact: A considerable proportion of 
apparently healthy people have one apex, usually the right, darker, 
due to various causes. In many it represents healed tuberculous 

1 Ztschr. f. Tube-kulose, 1911, xvii, 217. 

2 Rontgenatlas der Lungentuberkulose, Wurzburg, 1910. 



320 SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS 

lesions, which are no longer serious. When in these individuals there 
occurs a new tuberculous lesion in the opposite apex, which is not 
uncommon, it is responsible for the constitutional symptoms calling 
for a skiagraphic examination. The report from the radiographer may 
state that the lesion is located in the right side, while the physical 
signs show conclusively that the active lesion is in the left, or the 
reverse. 

The divergence of findings on physical examination and skiagraphy 
is best seen in far-advanced cases of phthisis in which a new lesion 
occurs in the hitherto unaffected apex. The plate does not show it 
distinctly until caseation has taken place, while physical exploration 
reveals it clearly. I have had this incontrovertible proof of the inade- 
quacy of skiagraphy in incipient lesions repeatedly. 

For these reasons ive should not conclude merely on finding opacities 
in one apex that ice are dealing with a case of active incipient phthisis. 
When found in connection with constitutional symptoms and signs on 
physical exploration these opacities are of diagnostic value. Nor should 
we conclude in the presence of constitutional symptoms and local signs 
suggestive of phthisis, but negative skiagraphic findings, that a case 
is not tuberculous. Such a case requires further observation, despite 
the negative a>ray findings. I do not hesitate to make a diagnosis of 
pulmonary tuberculosis under such circumstances when clinical evi- 
dence warrants it. 

After the apex we carefully examine the condition of the roots of 
the lungs, the hilus, with a view of ascertaining the presence of enlarged 
caseated or calcified glands or peribronchial infiltrations in that 
region. The shadows and mottlings observable at these points have 
been discussed. At first there was a tendency to consider all abnor- 
malities as evidences of enlarged glands and a diagnosis of tuber- 
culosis or tuberculous adenopathy was made on this evidence alone. 
But experience has shown conclusively that this shadow may be 
caused by any congestive condition of the bronchi and lungs, and it 
is not pathognomonic of phthisis. There is hardly an adult living in 
a city, or working at a dusty trade, who has no peribronchial thicken- 
ing, enlarged or calcified glands at the hilus of the lungs. It was also 
found by Cohn, Dunham, Boardman, Wolman, Bibb and Gilliland, 
and others, that except in cases with calcified glands, these shadows 
are caused by blood in the vessels of the thorax. Blood absorbs the 
arrays more readily than infiltrated soft tissue or sputum. Experi- 
mental injection of the arteries in the lungs intensifies the shadow, 
and in human beings injection of the vessels with substances giving a 
strong shadow produces pictures which are exactly like those of normal 
lung markings. 

This fact explains many of the thickenings and strands noted on 
chest plates, running from the hilus to the periphery of the lungs. 
In some cases they are due to bronchitis with congestion; in others, 
the mottling is due to calcified glands which are harmless and of no 



PLATE X 







Fig. 1 










F 




p 


J 


. 1 






I^K 




lH 




W* -:S 







Radiogram of a man with apparently healthy thoracic viscera. Dorsoventral position. 

Fig. 2 




Same man as in Fig. 1, but in the ventrodorsal position. 



PLATE XI 

Fig. 1 




Radiogram of a woman with apparently healthy thoracic viscera. 



Fig. 2 



Fig. 3 




Radiogram of the chest of a child eight 
years old. Though no symptoms or signs 
of tracheobronchial adenopathy could be 
found clinically, the radiogram shows 
shadows suggestive of such a condition. 




Radiogram of a child nine years old, 
suggestive of enlarged hilus glands. The 
symptoms and signs of this disease were, 
however, lacking. Yet on a level with the 
second rib an opacity suggestive of a 
calcified gland can be seen. 






PLATE XII 



Fig. 1 



Fig. 2 





Lung apex during ordinary breathing. 



Apex during ordinary breathing. 



Fig. 3 



Fig. 4 





The same apex while patient is cough- 
ing, and showing a narrowing " f +v, ° 



anu. snowing a iiairu\wng 01 the 

trachea, widening, and lightening up of 
the apices, especially the right. 
Hoist.) 



(F. 



The same apex while patient is coughing, 
showing narrowing of the trachea, and 
lightening up of the area of the lung. (F. 
Hoist.) 



The " Cough Phenomenon. 



PLATE XIII 



Fig. 1 



Fig. 2 



l 















CI 




HB 






HUB 


b-^lM 










Radiogram of a case of abortive tuber- 
culosis. Though suggestive of an extensive 
lesion in the left apex, the physical signs, 
as well as the course of the disease, showed 
that the activity of the process was 
benign. The patient recovered within 
three months. 



Radiogram of the apices in a case of 
incipient phthisis. No definite changes 
are visible, though physical exploration 
revealed a distinct lesion in the left apex, 
and the constitutional symptoms were 
clearly those of phthisis. 



Fig. 3 



Fig. 4 





Slight infiltration of the right apex. 
Marked increase in lymphatic tissue in 
both hilus regions. 



Partial consolidation of both apices, 
large cavity in left apex and thickened 
interlobar fissure. Dilatation of bronchi of 
lower lobe of left lung. Heart displaced to 
the left. 



PLATE XIV 



Fig. 1 



Fig. 2 





Infiltration of right apex. Peribronchial 
infiltrations and calcified glands at the 
hilus on both sides. 



Very dense infiltration of right upper 
lobe and large cavity below the clavicle 
limited below by the thickened interlobar 
fissure. Marked peribronchial infiltrations. 
The hilus region on both sides shows in- 
crease in lymphatic tissue. 



Fig. 3 



Fig. 4 





Large cavity surrounded by a dense 
fibrous wall in upper part of right lung. 
Enlarged glands in right hilus region. 
Lower half emphysematous. Left lung 
shows moderate infiltration beneath the 
clavicle and enlarged hilus glands. Drop 
heart. 



Bilateral tuberculous infiltration of both 
lungs. Dense hilus region due to calcifica- 
tion of glands. Several small cavities 
in right lung. Adhesions of diaphragm. 
Trachea markedly pulled over to the right. 
Stomach visible at left base. 



PLATE XV 



Fig. 1 



Fig. 2 



► 





Slight infiltration of both apices. Coarse 
infiltration of lower half of left lung with 
thickened pleura. Heart pulled over to 
the left and downward. Emphysema of 
right lung. Diaphragm in right side 
shows a bulging due to adhesions. 



Dense infiltration of upper third of left 
lung. The rest presents a dense homo- 
geneous shadow caused by consolidation 
of pulmonary parenchyma as well as 
thickened pleura. Right lung emphyse- 
matous and several enlarged and calcified 
glands are seen at the hilus. 



Fig. 3 



Fig. 4 





Chronic cavitary phthisis in a child 
eight years of age, with displacement of 
the heart to the left. 



Diffuse nodular infiltration of both lungs 
with multiple cavitation. " Honeycomb" 
appearance. 



PLATE XVI 



Fig. 1 



Fig. 2 





Dense infiltration of lower half of right 
lung with thickened pleura. Large cavity 
in left lung occupying apex on a level 
with first two interspaces. Drop heart. 



Diffuse infiltration of both lung apices. 
Round cavity, surrounded by a dense 
fibrous capsule, under the right third inter- 
space in mammillary line. Irregularity 
of the diaphragm due to adhesions. 



Fig. 3 



Fig. 4 





Large, oval-shaped cavity in right apex. 
Lymphatic tissue at hilus increased. 
Cavity in middle portion of left lung at 
third interspace. Heart dropped; pleuro- 
pericardial adhesions. 



Vertical heart. Multiple cavitation in 
right upper lobe, "honeycombed." Lower 
part emphysematous. Small cavities in 
left upper lobe. Marked hilus changes. 



RADIOGRAPHY 321 

clinical importance. Sewall and Childs report the case of a pre- 
sumably non-tuberculous stone-cutter furnishing a skiagram in which, 
except for the relatively moderate involvement of the apices, the 
mineral deposits occasioned opacities resembling the densest tuber- 
culous structure. I have often had the same experience with workers 
at dusty trades. The criterion given by some authors for distinguish- 
ing inactive consolidations and calcified glands from shadows repre- 
senting active lesions by the fact that the latter appear "wooly," 
does not hold in many cases. Any structure out of focus appears 
diffuse — "wooly"; even instantaneously taken plates are not free 
from this source of error. "The interpretation of less dense and more 
diffuse opacities is chiefly guesswork," say Sewall and Childs. 1 "They 
usually represent either pathological lymph nodes or bloodvessels in 
more or less optical section." 

Sources of Error. — The analysis of these shadows and mottlings 
admits of so many interpretations that they are of doubtful utility 
in most incipient cases. The "ground-glass" appearance of an apex 
is found in plates taken from healthy individuals. A shadow, when 
not the result of scoliosis, shows that there is some airless tissue in that 
location. But we are not justified in invariably assuming that it was 
caused by a tuberculous infiltration; or even if so, that the lesion is 
active. Ziegler and Krause, Dehn, Arnsperger and others have found 
that calcified and caseated tissue, and even fluid, anthracotic and 
calcified lymph glands, produce the same radiographic shadows. I 
have seen a large empyema failing to disclose itself on an .x-ray plate. 

There is no more justification for placing an individual, one of 
whose apices casts a shadow on a plate, under prolonged and costly 
treatment than there is for the treatment of one for mitral insuffi- 
ciency merely because he has a systolic murmur at the cardiac apex. 
In both cases the clinical symptoms decide whether the person is sick 
and in need of treatment. 

Because we are looking, in incipient cases, for small areas of recent 
infiltration, it is clear that we cannot rely on skiagraphy alone for the 
diagnosis of early phthisis. The skiagraphic picture gives the history 
of the thoracic viscera throughout the life of their owner. Any patho- 
logical change which may have occurred at any time may have left 
traces behind which are likely to cast shadows or cause opacities on the 
plate. For this reason, in incipient or dubious cases, the skiagraphic 
findings are to be taken only in connection with constitutional symp- 
toms and physical exploration of the chest. If the latter are negative, 
the case is to be considered non-tuberculous, no matter what the 
skiagraphic plate shows. 

It is thus clear that in the diagnosis of incipient phthisis the .r-rays 
are not of the value which some authors have attributed to them. 
Early tuberculous lesions, slightly enlarged bronchial glands, unless 

i Arch. Int. Med., 1912, x, 45. 
21 



322 SKIAGRAPHY IN THE DIAGNOSIS OF PHTHISIS 

caseated or calcified, as well as mucous secretions, usually permit 
the rays to pass through without casting any shadows on the plate. 
Optical sections of bloodvessels, due to any condition that may cause 
vascular engorgement, may show opacities on the plate simulating 
the characteristics of tuberculous lesions and may lead to error. 

AVhat is of most importance in obscure lesions is not so much their 
causation but their activity. A healed tuberculous lesion in an apex 
is not incompatible with excellent health, as has been repeatedly 
emphasized. But it produces a shadow on the skiagram as well as, 
often more striking than, an active lesion. 

Skiagraphy may be of great assistance in attempts at localization 
of a lesion, though smaller tuberculous foci may often be discovered 
with the orthodox clinical methods of diagnosis y and the determination 
of the activity of an apical process can only be accomplished by careful 
observation of the case, paying special attention to the constitutional 
symptoms, such as the temperature, the pulse, cough, expectoration, 
and the physical signs. "With our present ability to produce and 
interpret .r-ray pictures," say Sewall and Childs, "it must be admitted 
that a judgment founded on clinical history combined with physical 
signs may lead to a strong suspicion of tuberculous infection long before 
any signs of actual tissue changes, except those involving bronchial 
glands, appear on the ar-ray negative." Wolman, 1 who has worked 
with the stereograph, arrives at a similar conclusion. He says: "In 
the great bulk of cases the stereograph tells us no more than a careful 
clinical examination, yet in a fair number of cases, and those among 
the most interesting and puzzling, it gives additional information. 
But we must add the caution that a careful history is indispensable, 
since not even the stereograph can tell an active from a healed lesion." 

Skiagraphy in Advanced Stages of Phthisis. — In my experience skiag- 
raphy has been of greater utility in the diagnosis of advanced disease 
than in early or dubious cases. Very often we find that the .r-ray 
plate reveals more extensive involvement than the findings on physical 
exploration of the chest, and the prognostic significance is thus inval- 
uable. In cases in which the question of artificial pneumothorax is 
considered, skiagraphy offers invaluable assistance. Very ^of ten pleural 
effusions, especially the localized or interlobar varieties; pneumo- 
thorax and pleural adhesions are discovered, though they have escaped 
detection by routine methods. The same is particularly true of local- 
ized pneumothorax. 

The radiographic picture of advanced phthisis is variegated, depend- 
ing on the changes in the lungs and pleura. The intensity of the 
shadows cast by the lesions depends on their nature and density. 
Caseated and calcified areas cast dense shadows, while proliferation 
of tissue, especially when it is also congested, or fibrosis is also clearly 
detected. Old, indurated areas are usually more or less sharply demar- 

1 Johns HopkiDs Hosp. Bull., 1911, xxii, 236. 



RADIOGRAPHY 323 

cated from the surrounding tissues, while with new, active infiltrations 
the shadow merges by degrees with the surrounding air-containing 
lung tissue. Thick pleura is discovered by a dense, uniform shadow, 
and all connective-tissue formations reveal themselves in the same 
manner. More often than by physical exploration, cavities disclose 
themselves by showing limited areas lacking in lung markings and 
surrounded by thick shadows (Plate XIV). They may often be seen 
moving during inspiration and expiration when examined with the 
fluoroscopic screen. But when a cavity is filled with secretions it is 
again airless and casts the shadow of the surrounding tissues, and a 
very much thickened pleura may cover up a cavity. A cavity may also 
be screened by the surrounding healthy lung tissue. Thus, we often 
fail to find it with the .r-rays, while physical exploration reveals it 
easily. Sampson, Heise, and Brown 1 have recently shown that in 
many cases the annular or ringlike shadows seen often in almost 
normal or mildly infiltrated lung fields are no indications of intra- 
pulmonary cavities, as has been supposed by many, but altogether 
localized, usually interlobar pneumothorax. 

The differentiation between thick pleura and pleural effusions is 
very difficult in many cases. The following rule may be of assistance 
in some cases: When the signs found by percussion show a more 
extensive lesion than the radiogram shows, then it is the thickened 
pleura which produces the dulness. Conversely, when the signs 
obtained by percussion are of smaller extent than the radiogram 
reveals, there is a central parenchymatous lesion of very serious 
import. 

• The condition of the pleura may be studied on the plate. Fibrinous 
pleurisy is not shown at all. But effusions reveal themselves clearly 
as an intense shadow on the plate. Its upper level is not clearly demar- 
cated from the lung above, and in the fluoroscope it may be seen moving 
somewhat with the respiratory movements. When the quantity of 
fluid is small, it may escape detection when sinking down in the 
diaphragm. In hydropneumothorax it is important that the exposure 
should be made with the patient in the erect posture, because when 
lying down small quantities of fluid spread in a thin layer and may 
escape detection. In hydropneumothorax the upper layer of the fluid 
forms a sharp line, while in pleurisy with effusion the upper level is 
usually not so sharp, but gradually merges with the lung tissue above 
it. The fact that in the latter case the level does not shift with motion 
of the patient's chest shows that it is not a hydropneumothorax; 
in the latter case it does shift (see Plate XX). 

The displacements of the mediastinum caused by pleural effusion 
are best made out with the .r-rays; but it is impossible to distinguish 
between fluid and the liver in right-sided effusions. Dislocation of the 
trachea and larynx may often be discovered on the plate (Plate XV). 

American Review of Tuberculosis, 1919, ii, 664. 



CHAPTER XVIII. 

THE CLINICAL FORMS OF PHTHISIS. 

POLYMORPHISM OF THE CLINICAL PHENOMENA OF 
PHTHISIS. 

Laennec showed clearly the unity of the elemental pathological 
changes found in phthisis, and Koch, discovering the tubercle bacillus, 
proved it etiologically. But all attempts to impose this unity on the 
clinical manifestations of tuberculous diseases of the lungs have failed 
dismally. In pathology, particularly in clinical medicine, unity of 
causation does not always indicate unity of effect. Especially is this 
true of a polymorphous disease, as pulmonary phthisis. 

A study of the morbid anatomy of phthisis shows great polymor- 
phism — there are hardly two cases showing the same changes in 
structure. There are cases in which the lesions are purely proliferative, 
characterized by the formation of tubercles, as is the case with acute 
miliary tuberculosis; in others they are mainly exudative, as in chronic 
phthisis. But in the latter the difference in the intensity of the pro- 
ductive inflammation, which tends to limit the morbid process; and 
the process of necrosis, which tends to extend it, produce a diversity 
of lesions which have important bearings on the clinical picture, 
course, and prognosis of the disease. 

This is to be expected when we consider that the disease produced 
by the tubercle bacilli depends on the interaction of two forces of 
inconstant intensity, viz.: 

1. On the intensity of the infection. This depends on the number 
of bacilli which have entered the body; their virulence which we 
know is variable, depending on the type and the condition under 
which they existed before entering the body, etc., and on the portals 
of entry. It is doubtful whether infection by inhalation will produce 
the same clinical picture as infection by ingestion or by inoculation; 
whether hematogenic tuberculosis will produce the same symptoms 
as aerogenic or lymphogenic infection. 

2. On the resistance of the host, which is also an inconstant value, 
depending as it does on certain and uncertain, constant and tempo- 
rary conditions which cannot always be defined clearly. Thus, the 
effects of the infection depend on the age at which it has taken place. 
During the first six or twelve months of life massive infection pro- 
duces a different disease from that of the succeeding years of child- 
hood. Acute miliary tuberculosis is common at the former age, while 
tuberculosis of the glands, bones and joints is mostly seen at the later 
ages. Primary infection of an adult is usually followed by clinical 



OFFICIAL CLASSIFICATIONS OF STAGES OF PHTHISIS 325 

phenomena which differ markedly from those seen in individuals who 
were presumably infected during childhood, and the bacilli remained 
dormant for many years. We have already discussed the effects of 
preexisting diseases on the type and course of phthisis. 

"To speak of pulmonary tuberculosis as an entity," says von Hanse- 
mann, 1 "and to describe it as one disease caused by the tubercle 
bacillus is hardly conceivable. One has to compare pure miliary tuber- 
culosis of the lungs with chronic indurative phthisis, and the latter 
with acute florid phthisis or caseous hepatization of the lungs, to find 
clearly that they are different pathological pictures which defy all 
comparisons. For these reasons it is altogether impossible to speak 
simply of pulmonary tuberculosis and thereby retain a clear survey 
of the different forms of the disease. In reality we are compelled to 
draw a sharp line of demarcation between these different forms of 
the disease, even when we are inclined to consider the tubercle bacilli 
as the underlying etiological cause of all the forms of the disease." 

The Stages of Phthisis. — Early writers on phthisis, who were 
innocent of modern methods of diagnosis, felt constrained to differ- 
entiate various forms of the disease as they saw it clinically. They 
divided it into three stages: Phthisis incipiens, phthisis confirmata, 
and phthisis desperata. Bayle, in the first decenium of the nineteenth 
century, added a fourth stage, Phthisis occulta, or germe de la phtisie, 
which corresponds to the modern pretuberculous stage, when the 
tubercles in the lung are too few to produce symptoms. Laennec, 
who was an excellent and pioneer pathologist and clinician, having 
invented auscultation, divided phthisis into three stages, basing his 
classification on anatomical grounds. He divided phthisis into: 
First stage, the accumulation of the tubercles, which betray themselves 
by bronchophony and dulness over the affected area; second stage, 
softening of the lesion, producing bronchial breathing, coarse rales 
and pectoriloquy; and third stage, the elimination of the softened 
area, leaving pulmonary excavations which may be found by careful 
physical exploration. 

This division of phthisis into three or four stages has remained 
to date not only among the laity, who fear the second and third 
stages, but also among physicians, who are always aiming at discover- 
ing the disease in the pretuberculous stage, or at least in the first, 
or incipient stage. Some even maintain that the disease is curable 
only at this stage. That this is not always true will be shown later on. 

OFFICIAL CLASSIFICATIONS OF THE STAGES OF PHTHISIS. 

With the advance of knowledge of the clinical manifestations and 
the methods of recognition of the disease, the stages into which phthisis 
is divided remained practically the same. They have only been more 

1 Berl. klin. Wchnschr., 1911, xlvii, 1. 



326 THE CLINICAL FORMS OF PHTHISIS 

exactly defined. In Germany the classifications of Turban and 
Gerhardt have gained wide acceptance, while in this country the 
American Sanatorium Association and the National Association 
for the Study and Prevention of Tuberculosis have adopted the 
following classification: 

Incipient. — Slight initial lesion in the form of infiltration limited 
to the apex of one or both lungs or a small part of one lobe. No 
tuberculous complications. Slight or no constitutional symptoms 
(particularly including gastric or intestinal disturbance or rapid loss 
of weight). 

Expectoration usually small in amount or absent. 

Tubercle bacilli may be present or absent. 

Moderately Advanced. — No marked impairment of function, either 
local or constitutional. Localized consolidation moderate in extent 
with little or no evidence of destruction of tissue or disseminated 
fibroid deposits. No serious complications. 

Far Advanced. — Marked impairment of function, local and con- 
stitutional. Localized consolidation intense, or disseminated areas of 
softening, or serious complications. 

Shortcomings of the Official Classifications. — If the object of this 
classification is to define the prognosis of phthisis, it fails utterly. A 
patient with a " slight initial lesion in the form of an infiltration of the 
apex" has not always a greater expectation of life than one having 
"marked local impairment of function and extensive destruction of 
tissue." In fact, in acute miliary tuberculosis of the lungs the lesion 
is so slight that it often cannot be localized during life. On the other 
hand, many cases of phthisis with extensive excavations have a better 
outlook, at least as regards duration of life, and even as regards regain- 
ing efficiency, than some with limited lesions at one apex, without 
expectoration of tubercle bacilli but with evidences of toxic activity. 
Moreover, it is clinically wrong to put into one class the incipient cases 
showing no fever, no tachycardia "at any time during the twenty- 
four hours," no gastric or intestinal disturbances, no rapid loss of 
weight, etc., which are evidently cases of abortive tuberculosis, if at 
all actively tuberculous, with those having lesions limited to one or 
both sides and who do show constitutional symptoms of toxemia. 
The former will recover within a few months under any rational form 
of treatment, or spontaneously, while the latter may not, even with the 
most rigid institutional, climatic, dietetic, or specific treatment. 

Physicians having opportunities to observe many tuberculous cases 
are struck with the fact that the prognosis, immediate and ultimate, 
does not entirely depend on the changes in the breath sounds, the 
presence or absence of rales and signs of excavations in the lungs. 
The constitutional symptoms, such as fever, pulse-rate, presence or 
absence of dyspnea, gastric disturbances, and above all the resistance 
of the patient, play a greater role in the ultimate outcome of a case 
than the anatomical changes. 



OFFICIAL CLASSIFICATIONS OF STAGES OF PHTHISIS 327 

In order that a case may be considered " incipient," according to 
this classification, and nearly all others which have been devised, the 
constitutional disturbances must be slight or absent. Thus, in the 
definition of terms it is stated that "the impairment of health may be 
so slight that the patient does not look or feel sick in the ordinary 
sense of the word." The pulse should not exceed 90 per minute and 
the temperature 99.5° F. and the sputum may be negative. The 
physical signs consist in "slight prominence of the clavicle, lessened 
movement of the chest, narrowing of the apical resonance with les- 
sened movement of the base of the lung, slight or no change in reso- 
nance, distinct or loud and harsh breathing with or without some 
changes in the rhythm (i. e., prolonged expiration), vocal resonance 
possibly slightly increased; or fine or moderately coarse rales present 
or absent. If sputum contains tubercle bacilli, any one of these." 
Considering that the apex is defined as "that portion of the lung 
situated, above the clavicle and the third vertebral spine," it is clear 
that the lesion must be quite limited, often of the type considered 
"dubious" by some clinicians. 

All these symptoms or absence of constitutional symptoms and 
signs in the chest may be found in a large proportion of persons in all 
walks of life, working hard at their occupations, who, if followed for 
many years, are not found to develop active phthisis. People with 
collapse induration often show more distinct physical signs at one 
apex, yet they are not phthisical. 

On the other hand, a really phthisical person showing so few signs 
on physical exploration, but in whom the disease is pursuing an acute 
or subacute course, may be carried off much quicker than many with 
extensive involvement, bat manifesting a tendency to chronicity of 
the process. 

It cannot be denied that these three or four stages of tuberculosis 
are altogether arbitrary. We cannot often separate them by sharp 
lines of demarcation and say "this is a first stage case," or "this case 
is passing from the second into the third stage," etc. There are 
always transitional forms. There are also numerous cases showing 
healed lesions which at the time of activity were in the third stage, 
but give no more trouble — while an initial lesion in the other lung is 
responsible for the disease for which the patient consults the physician. 
Such cases, incipient in the true sense of the word, must be considered 
far advanced according to this classification. It is also a fact that, for 
phthisis to end fatally, it is not necessary that the lesion in the lung 
should soften and produce a cavity; caseation alone, when extending 
rapidly, may kill; the patient has thus not reached the third stage, 
yet he dies. On the other hand, we have numsrous patients who, 
despite the fact that they have more or less extensive excavations in 
the lungs, are in fact in the third stage of phthisis, yet they feel well, 
and are even efficient at their occupations, and when they finally die 
the cause may be another disease. 



328 THE CLINICAL FORMS OF PHTHISIS 

For these reasons some clincians have been constrained to distinguish 
the various forms of phthisis met with in practice into different clin- 
ical entities. Thus, even the classification mentioned above considers 
acute miliary tuberculosis as a distinct disease. Other authors, like 
Alfred Loomis, Williams, Andrew Clark, Douglas Powell, etc., have 
described fibroid phthisis — which in the above classification would 
always be included among the advanced cases — as a distinct disease. 

Many writers on this subject have gone much further and distin- 
guished not only acute and chronic forms of the disease but have also 
described congenital, or hereditary and acquired forms of the dis- 
ease; phthisis in arthritic, gouty, diabetic, nephritic, alcoholic, or 
syphilitic subjects; also according to some prominent symptoms, such 
as hemorrhagic, bronchitic, bronchiectatic, pleuritic phthisis. In 
accordance with certain etiological factors, there has been described 
phthisis in workers at dusty occupations, such as miners' phthisis, etc. 
Finally tuberculosis of the lungs in children has always been consid- 
ered as presenting a different clinical picture from that in the adult; 
while in aged persons the symptomatology of phthisis differs from 
that in younger individuals. 

Classification in the Present Work. — The classification of the 
diversity of clinical types of tuberculosis of the lungs, to be of practical 
value, if it is to be attempted at all, must have a prognostic value. 
For this reason the acute forms of the disease are to be separated into 
a class by themselves, as has, in fact, been done by all writers on the 
subject. In chronic phthisis the ultimate outcome of the disease 
depends mainly on the relative intensity of the two processes in the 
lungs, the destructive and the reparative, the former manifesting 
itself by caseation and softening, and the latter by the formation of 
fibrous tissue which limits the destructive process and even heals 
the lesion by cicatrization. Both processes, fibrosis and necrosis, are 
caused by the tubercle bacilli. And inasmuch as there are many cases 
in which the fibrosis dominates the anatomical changes in the lungs, 
and the symptoms thus produced differ from those in which the 
caseating process predominates, it is clear that there is justification 
for separation of fibroid phthisis into a distinct class of the disease. 
This justification is fortified by the fact that the prognosis of fibroid 
phthisis is distinctly more favorable than that of chronic caseous 
phthisis, and the treatment indicated is different from that in other 
forms. 

In common chronic phthisis we find that among the cases which 
have been described as " incipient" there are many which show a 
marked tendency to cicatrization of the lesion, spontaneously or after 
some treatment for a few months. In the vast majority of cases 
this form of phthisis is not at all recognized and only at the autopsy 
some scars or calcified foci are found in the lung or pleura showing 
that the person had survived a tuberculous lesion. To treat these 
cases in the same manner as we treat common chronic phthisis is 
wrong. We should, when diagnosticating a case of this kind, tell the 



OFFICIAL CLASSIFICATIONS OF STAGES OF PHTHISIS 329 

patient that his malady is relatively trifling, and that he will recover 
within a few months, if he observes ordinary hygienic and dietetic 
rules. We can often also spare him the trouble and the economic 
danger of giving up his business which is usually necessary in cases 
of chronic phthisis. We have therefore described abortive tubercu- 
losis as a distinct clinical type of the disease. 

Most of the victims of tuberculosis who succumb to the disease or 
who suffer from it for long periods of time even if they recover are 
affected with chronic phthisis. This disease is characterized by an 
undulating course marked by periods of quiescence of longer or 
shorter duration, and interrupted by periods of acute or subacute 
exacerbations. In fact, it may be stated that acute progressive phthisis, 
or galloping consumption, consists clinically in an acute exacerbation 
of the disease which is not followed by a period of quiescence. In the 
chronic type of the disease, proper and timely treatment may save 
the patient, while negligence in this regard is apt to prove disastrous. 
For this reason it is imperative that it should be recognized as early 
as possible. We have therefore divided the subject into two parts: 
incipient phthisis and advanced phthisis. The former, if recognized 
in time, and appropriate treatment applied, may often be aborted; 
or acute exacerbations leading to irreparable damage of the lungs and 
other organs and functions may be prevented. The latter, when 
properly cared for, may be kept in check so that acute exacerbations 
occur less frequently, or not at all, and cicatrization of the lesion goes 
on unhindered. 

We also know that tuberculosis in children is anatomically, and also 
clinically, not of the same character as that in adults. In the former 
the glands, bones and joints, while in the latter the lungs, are mainly 
the organs which bear the brunt of the infection. Indeed, consider- 
able harm is done to children by treating them for chronic pulmonary 
tuberculosis which, before the eighth year of life, they practically 
never have. For this reason, the disease as it occurs in infants and 
children merits separate description. Because in infancy the infec- 
tion is usually followed by acute manifestations, while in children 
between two and ten years of age chronic disease of the glands occurs, 
we shall speak of tuberculosis in infants and tuberculosis in children. 

Finally, it is now known that phthisis occurs in the aged just as 
frequently as in younger individuals, but that it is not recognized 
very often because of the peculiar symptomatology it presents. The 
aged consumptives, believing that they only suffer from chronic 
bronchitis, asthma or pulmonary emphysema, are sources of infection 
to an extent not so fully appreciated as they deserve. We have there- 
fore devoted a special chapter dealing with tuberculosis in the aged, 
pointing out its clinical characterization. 

While in nearly every case of pulmonary tuberculosis the plerua is 
implicated in the process, more or less, there are cases in which the 
disease begins in the pleura and shows no tendency to spread into the 



330 THE CLINICAL FORMS OF PHTHISIS 

pulmonary parenchyma. In others, the pleural lesion is the main one 
with which the patient has to cope. Moreover, it appears that the 
vast majority of pleurisies which had formerly been considered "idio- 
pathic," are in reality tuberculous in character. For these reasons a 
book on pulmonary tuberculosis -is incomplete unless a detailed 
account is given on tuberculosis of the pleura. 

These forms of phthisis do not exhaust the subject of the clinical 
polymorphism of this disease. There are many other types which 
may be appreciated when carefully studying the cases, while quite 
often these types overlap one. another to an extent as to render it 
difficult to decide to which class a case belongs. But for practical 
purposes these clinical classes are sufficient. They assist in appreciat- 
ing the course of the disease when it occurs, and give us hints for prog- 
nosis and treatment which are invaluable, and which cannot be had 
when pulmonary tuberculosis is considered as a single clinical entity. 

We shall therefore describe phthisis under the following headings : 

1. Chronic phthisis, incipient stage. 

2. Chronic phthisis, advanced stage. 

3. Acute phthisis. 

4. Fibroid phthisis. 

5. Abortive pulmonary tuberculosis. 

6. Pulmonary tuberculosis in children. 

7. Phthisis in the aged. 

8. Tuberculosis of the pleura. 



CHAPTER XIX. 
CHRONIC PHTHISIS, INCIPIENT STAGE. 

INCIPIENT PHTHISIS. 

Onset. — A lay writer, 1 describing his own subsequently fatal case 
of phthisis, in speaking of his "initiation into T. B.," says: "The 
entrances are innumerable, however sole the exit. Indeed, the initia- 
tion varies so widely that one would not be far wrong in saying that 
it is never twice the same. Yet many initiations have certain features 
in common; and in a general way it may be said that all belong to 
one of two great classes — the sudden and the protracted." No 
physician, however extensive his experience with phthisis, could do 
more justice to the subject, or make a better generalization of the 
various ways in which phthisis is likely to begin. 

A sudden or abrupt onset of phthisis is infrequent, but it does occur. 
We meet with patients who have been in the best of health; have no 
ascertainable hereditary taint; have not come into immediate or 
intimate contact with a consumptive, so far as they can remember; 
have not overworked, not suffered from exposure, but they suddenly 
begin to cough, lose weight, have fever, feel tired at the least exertion, 
and a careful physical examination reveals a small, but progressive 
lesion at one apex. We meet with others who, without any premonitory 
symptoms, without any exciting cause, suddenly perceive a warm 
sensation in the throat, cough, and bring up a mouthful of blood . The 
hemoptysis may be scanty or copious, but the signs elicited while 
examining the chest leave no doubt that it is derived from a pulmonary 
lesion, and the subsequent course of the disease proves conclusively 
that we are dealing with phthisis. Still others, after an indiscreet 
exposure to the vicissitudes of the weather, or after a cold bath to 
which they are not accustomed, begin to cough and are treated for a 
"cold," "grippe," etc., for some time. But the symptoms fail to 
ameliorate in spite of careful treatment, when one day a careful 
examination of the chest shows a distinct lesion, or a bacteriological 
examination of the sputum reveals the presence of tubercle bacilli. 
In some, exposure may bring on an attack of pleurisy, dry or with 
effusion, the subsequent course of which is distinctly that of phthisis. 

But in a large proportion of cases the disease develops slowly, insidi- 
ously — the initiation is protracted, as our lay friend said. For months, 
a year or two, the patient has not been well. He was "subject to colds," 

1 Atlantic Monthly, June, 1914, cxiii, 747. 



332 CHRONIC PHTHISIS, INCIPIENT STAGE 

and in autumn or winter he passed through one or more attacks 
of "grippe," bronchitis, etc., with cough, expectoration, fever, malaise, 
etc., but he soon recuperated and worked more or less efficiently at 
his vocation. Finally one attack sticks and he does not improve, not- 
withstanding the remedies which were formerly effective. 

In young men the symptoms which we are apt to label as "neuras- 
thenia," may have been present for a year, two, or more. What was 
most annoying, and could not be relieved by the usual treatment 
instituted, was the languor, the tired feeling which overwhelmed the 
patient before his day's work was at an end. He may be complain- 
ing of cardiac palpitation, indefinite pains in the chest, some cough 
in the morning, etc. But on the whole he considered himself "run 
down," and sadly in need of a rest. 

In young women the subjective and objective symptoms of chlorosis 
may have been present for months or years. An examination of the 
blood has, indeed, shown a low percentage of hemoglobin, and large 
doses of some iron preparation have been used. Some have had 
irregularities in the menstrual function, perhaps amenorrhea for 
several months, and even this was attributed to the anemia. But 
then they begin to cough; and the cough persists in spite of treat- 
ment, when an examination of the chest or of the sputum tells the story. 

Others have been "run down" from overwork, physical or mental, 
for a long time till it is discovered that the cause of their debility is 
located in the lungs. In many patients the symptoms of dyspepsia 
are so pronounced as to preclude a careful examination of the chest 
and they are treated for a long time for "stomach trouble." 

This does not exhaust the variety of symptoms which may slowly, 
but surely, usher in phthisis. But numerous as they are, they have 
certain features in common which characterize phthisis in the vast 
majority of cases, so that if this disease is only borne in mind — and it 
should, considering its great prevalence— more really incipient cases 
would be recognized than at present. These clinical phenomena will 
now be discussed. 

Symptoms. — Practically all patients with incipient phthisis cough 
at a very early stage of the disease, and the cases without cough, 
which have been mentioned by various authors, are rare clinical 
phenomena, at least they are exceedingly rare among persons under 
fifty years of age, and may be disregarded. It was already stated that 
patients who claim that they do not cough are usually individuals 
who overlook a mild cough, but those around them are apt to notice 
that they do, and in doubtful cases it is advisable to inquire among 
those who live with the patient. 

A person who never coughed before, but after a "cold" coughs for 
more than two weeks should excite interest and careful study. If he 
vomits after fits of coughing, tuberculosis is to be strongly suspected. 
Paroxysmal coughing spells are also apt to take place during the night 
and keep the patient awake. Very little expectoration is apt to be 



INCIPIENT PHTHISIS 333 

brought up at this period — at most some viscid mucus which contains 
no tubercle bacilli, nor elastic tissue, though animal inoculation may be 
effective in disclosing the tuberculous nature of the trouble. 

Languor is a constant symptom at a very early stage — the patient 
feels tired in the morning at rising, but recuperates after working for 
a few hours. But in the later part of the afternoon he feels fatigued, 
often drowsy, inclined to sleep. It is this tired feeling which is to be 
held responsible for the fact that so many patients are erroneously 
treated for neurasthenia and psychasthenia, or for a "nervous break- 
down," for a long time until the true nature of the disease is finally 
ascertained. 

Anorexia is an inconstant and variable symptom of incipient 
phthisis. In some, especially in youthful subjects, it is very frequent 
and, coupled with anemia, constipation, etc., is the cause why so 
many are treated for chlorosis, gastritis, etc. There are many cases 
in which the appetite is well retained and, when not "dieted" with a 
view of improving nutrition and digestion, but urged to eat well and 
plenty of the foods they are accustomed to eat, they do not lose in 
weight, but may gain, even when the process in the lung goes on 
actively. 

But in the majority of cases a persistent loss of weight is noted at 
this period. In some it is slow, only one pound per week on the aver- 
age, while in others it is more rapid and during the first two months 
fifteen or twenty pounds may be lost. 

The activity of the process is best estimated by the fever, which is 
never absent. It may be slight, only 1° elevation in the afternoon, but 
it can be found in every case by the judicious use of the thermometer. 
A subnormal temperature during the early morning hours, best looked 
for by taking it per rectum before the patient leaves his bed, is very 
frequently observed, and of immense diagnostic significance. In many 
the fever subsides when the patient is kept in bed for a couple of days 
but reappears as soon as some exercise is allowed. In those with 
an apparently normal temperature, fever may be provoked by walking 
or any other form of exercise, as was already discussed in detail (see 
page 187). In women, the fever may appear only during the menstrual 
period or a few days before. 

In a large number of cases pyrexia is considerable even at this 
early stage, up to 102° or 103° F. in the afternoon and evening and, 
measured by comparison with the subnormal temperature in the 
early morning hours, it is quite high. The "reversed type" of fever, 
with a rise in the morning, is occasionally seen. 

A significant diagnostic point is that with high fever the patient 
may not be prostrated as is the case with adults who have fever due 
to other causes. Moreover, the patient may have a fair, even a good 
appetite, despite the fact that the thermometer registers 102° or 103° 
F., which is very rare in fevers due to other causes. During the 
afternoon access of the fever, the patient, otherwise pale, becomes 



334 CHRONIC PHTHISIS, INCIPIENT STAGE 

flushed, often only one cheek is red, he is tired and disinclined to 
work. But he may keep on working, as was already stated. 

Nightsweats make their appearance in a large proportion of cases 
at this stage. In some they are slight, while in others I have met 
with profuse nightsweats during the first two weeks of active sym- 
toms. They perspire also at the least exertion or excitement, and 
during a medical examination it is not rare to see large drops of sweat 
dribbling down the sides of the chest from the axillae. A constant 
accompaniment of fever in incipient cases is tachycardia. A case of 
active phthisis with a pulse-rate below 80 per minute is exceedingly 
rare. In some the heart action is so rapid that they are treated for 
heart disease, or for hyperthyroidism in case the thyroid is enlarged, 
which is not rare, especially in youthful individuals. While in the 
early morning after a refreshing sleep the pulse-rate may be normal, 
the least exertion or excitement will raise it up to 90, 100 or more. 
Instability of the pulse is characteristic of phthisis. In youthful sub- 
jects the tachycardia is apt to be more pronounced than in persons 
over twenty-five years of age. The blood-pressure is low and a regis- 
tration less than 80 mm. of mercury is quite common. 

Symptoms referable to the respiratory system may not be seen at 
this stage, excepting the cough and, at times, the intermittent hoarseness, 
which is usually due to a laryngeal catarrh, or pressure on the laryngeal 
nerve, and hardly ever to infiltration of the larynx. At times we see 
patients who suffer from more or less pronounced pains in the chest, 
especially under the scapula, or in the shoulder. 

Hemoptysis is quite frequent at this stage. As was already stated, 
statistics taken of large numbers of patients show that about 10 per 
cent, of cases begin with hemorrhage. They are the lucky ones, 
because this clears up the case, and proper measures are promptly 
taken. But many of these initial hemorrhages were actually preceded 
by a train of symptoms, such as fever, tachycardia, etc., to which the 
patient paid no attention. However, in about 25 per cent, of cases 
more or less blood-spitting occurs at the time the disease is recog- 
nized. It may be only blood-tinged sputum, a mouthful or two of 
blood, or even a profuse hemorrhage. It will bear repetition that 
these hemorrhages are practically never fatal. 

Physical Signs. — With any or all of these symptoms a diagnosis of 
incipient tuberculosis should not be made unless physical exploration 
of the chest discloses a localized lesion in the lungs. 

Inspection. — Inspection yields excellent diagnostic criteria in most 
cases at this earlv stage. Inasmuch as most of the incipient cases 
are really recrudesces of old quiescent lesions dating back to child- 
hood, we find m many atrophy of the muscles over the site of the 
lesion. The sternocleidomastoid, the scaleni and trapezius, etc., may 
be smaller than those on the opposite side and softer, or even flabby 
to the touch. This is more important to look for than the form of the 
chest, which may be normal, flat, rachitic, etc., without influencing the 



INCIPIENT PHTHISIS 335 

diagnosis. With the atrophy of the muscles there is usually seen a 
slight shoulder-droop and an excavation of the supraclavicular or 
supraspinous fossa, or at least some flattening and defective motion or 
lagging of the part of the chest harboring the lesion. This asymmetry, 
flattening and lagging, is very easy to detect if carefully looked for 
and is, when found, of immense diagnostic importance, provided 
occupational influences are excluded. 

In more recent lesions, or when an old lesion exists in one side but 
the outbreak of phthisis is due to a new lesion in the opposite side, 
which is very frequent, we find the muscles over the site of the active 
new infiltration are tense and rigid, standing out prominently. But 
this is after all not very frequent, which goes to show that most of 
the incipient cases are really due to reawakening of old, smouldering, 
tuberculous processes in the lung. 

Percussion. — As was already stated, there are very few cases of active 
incipient tuberculosis in which no signs of an infiltration can be dis- 
covered by careful and gentle percussion. We almost invariably find 
some airless pulmonary tissue or shrinkage of one apex manifesting 
itself by a short note or by pulmonary retraction. The height of the 
apex may be less than that of its mate on the opposite side, or its width 
may be less, as determined by Kronig's method of percussion. We 
may also find, though not so often as Kronig believed, that the base 
on the affected side is somewhat retracted. Immediate percussion of 
the clavicle, as was first practised by Laennec, may at times easily 
reveal a lesion beneath that bone. 

In my own experience, percussion signs are more often found over 
the posterior aspects of the apices than anteriorly. While over the 
supraclavicular region we may find that the width of the resonant 
area is less than that of the other side, it is easier and less time-con- 
suming to map out the mesial lines of demarcation between resonance 
and dulness in the supraspinous fossa?, and over the site of the lesion 
this line is usually dislocated outward. 

It is also easily ascertained whether the height of the apices poste- 
riorly shows any asymmetry. At a very early stage we find that while 
over the unaffected apex the resonance reaches as far as the interval 
between the seventh cervical and first thoracic spines, that of the 
affected apex is much lower. I have found these changes at times 
before any auscultatory signs made their appearance. 

The changes in pitch, duration and intensity of the note obtained at 
this stage are of less significance than those of shrinkage just spoken of, 
and they depend too much on the personal equation of the observer 
to have important clinical bearings. Thus, we often find that a con- 
tracted apex is altogether hyperresonant or even tympanitic on per- 
cussion, and by comparison the unaffected side appears to emit a defec- 
tive note. The stories told in text-books about two equally competent 
clinicians localizing an apical lesion by percussion and each finding 
it in another side, are undoubtedly based on these facts. It is generally 



336 CHRONIC PHTHISIS, INCIPIENT STAGE 

due to faulty interpretation of tympany caused by relaxation and 
hyperfunction of the lung tissue around conglomerations of tubercles, 
as has already been shown. The discordance may also be due to an 
old and cicatrized lesion on one side, while the new and active lesion 
is in the opposite side of the chest. . 

Of greater importance is respiratory percussion. The patient is 
asked to inspire or expire and hold his breath, and we percuss during 
each phase of respiration. In health the note is clearer during full 
and held inspiration, while over an infiltrated apex a long and held 
inspiration gives a duller note than found over the opposite, unaffected 
side. 

Of the various seats of election of dulness in incipient phthisis which 
have been described by Lees, 1 Riviere, 2 and others, the sites I have been 
able to find impaired in most cases at a very early stage are the supra- 
spinous fossae, near the spine, and beneath and above the inner third 
of the clavicle. Persistent, impaired resonance in any of these places, 
when accompanied by constitutional symptoms of phthisis, is of diag- 
nostic significance. Impaired resonance elicited with hooked-finger 
percussion between the heads of the sternocleidomastoid immediately 
above the clavicle on one side is very often found. 

Auscultation. — It is not generally appreciated that the earliest 
changes in the respiratory sounds in phthisis are modifications of 
the inspiratory murmur, while changes in the expiratory murmur 
usually indicate a more or less advanced stage of the disease. At a 
very early period of the disease the inspiratory murmur loses its soft, 
breezy character and becomes rough or granular, an indication of par- 
tial stenosis of the bronchioles supplying the affected part of the lung, 
or unequal respiratory movement of the infiltrated lung area. In 
many cases the inspiratory murmur is feeble, at times even absent, 
over a limited area corresponding to the area of impaired resonance, 
while the whispered voice is transmitted clearly. But the most com- 
mon sign of an early lesion is interrupted, or cog-wheel breathing, the 
inspiratory sound is broken up into several parts so that it appears 
jerky. Either of these types of altered inspiratory murmur may be 
audible long before the expiratory murmur is in any way changed. 

The most common seats of the changed breath sounds are poste- 
riorly near and above the spine of the scapula, the "alarm zone" of 
Chauvet, 3 and rarely in front immediately beneath the inner third of 
the clavicle. It is located posteriorly as follows: From the center 
of the space separating the spinous process of the seventh cervical 
from that of the first thoracic, a line is drawn as far as the tubercle of 
the trapezium on the spine of the scapula. From the middle of this 
line, taken as a center, a circle is described with a diameter equal to 
that of a silver dollar. The circumference of this circle forms the 

1 British Med. Jour., 1912, ii, 1268. 

2 Early Diagnosis of Tubercle, London, 1914, p. 25. 

3 Le monde medical, 1913, xxii, 1121; La Clinique, 1913, viii, 437. 



INCIPIENT PHTHISIS 



337 



boundary of the "zone of alarm" (Fig. 61). When heard at any of 
these points during ordinary breathing, and repeatedly found on 
several examinations, not decreasing in intensity but on the contrary 
becoming more and more pronounced, rough and cog-wheel breathing 
are good signs of incipient infiltration of an apex, provided of course, 
that the constitutional symptoms show activity; otherwise they may 
be indications of old and cicatrized lesions. We have already stated 
that at times feeble breath sounds are found; they may be of a blow- 
ing or even of a bronchial character, and some crackling may be 
audible at the end of inspiration. 




Fig. 61. — 1, The "alarm zone;" 2, the space between the spinous processes of the 
seventh cervical and first dorsal vertebrae; 3, the tubercle of the trapezius. 



Rales are not heard at all over really incipient lesions. Occasionally 
some sibilation is audible, but this is usually transitory and disappears 
after the patient takes a deep breath. At most, some dry crackling 
may be brought out when the patient coughs vigorously. When crepi- 
tant, and especially moist subcrepitant, rales are audible, we are dealing 
with an extensive lesion of some duration. 

In some cases we hear at a very early stage during expiration a 
hemic murmur originating in the subclavian artery and ascribed to 
kinking of that vessel by the tuberculous infiltration, or by shrinking 
22 



338 CHROXIC PHTHISIS, INCIPIENT STAGE 

lung. But it is by no means pathognomonic of phthisis because it is 
heard in many apparently healthy persons. 

The whispered voice is very often transmitted more or less clearly 
over consolidated areas of lung tissue and when heard when the chest- 
piece of the stethoscope is pressed firmly over the skin of the chest, it 
is of the same diagnostic significance as impaired resonance, with 
which it usually rims parallel, as has been pointed out by Sewall. 1 
But it must be emphasized, that its absence does not exclude a tuber- 
culous lesion. The voice sounds are transmitted only when the con- 
solidated tissue is located superficially or subpleurally. When it is 
centrally located, screened by air-filled lung tissue, the voice sounds 
may be normal. 

To be of diagnostic significance in early phthisis, the auscultatory 
signs must be localized over one apex, circumscribed, fixed and per- 
sistent for some time, and not influenced by cough and strong respira- 
tory efforts, excepting clicks and rales which may be brought out by 
cough. Evanescent changes in resonance and breath sounds may be 
found in many apparently healthy persons. It is for this reason that 
many who attempt to make a final diagnosis of incipient phthisis 
during one examination meet with so many failures. 

Elements of Diagnosis of Incipient Phthisis. — Just as the general 
and constitutional symptoms, such as cough, fever, tachycardia, ema- 
ciation, etc., are insufficient to decide a case till the lesion is localized 
in the lung, so are the signs obtained by physical exploration of the 
chest inadequate, even when marked, to prove that we are dealing with 
a case of active incipient phthisis. Only the combination of both groups 
of clinical data gives solid support for diagnostic inferences. A skilled 
diagnostician may easily diagnosticate a case of advanced phthisis 
by looking at the pathognomonic facies of the patient, from the his- 
tory and course of the disease, or from auscultatory findings alone, 
and only rarely err. But in incipient phthisis it is the correlation of 
all available clinical data, the history, the symptomatology and course 
of the disease, combined icith the findings of physical exploration of the 
chest that can be expected to clinch the diagnosis. 

The signs enumerated above — defective resonance, narrowing of the 
resonant areas over one apex, feeble, rough, granular or cog-wheel 
breathing, or even rales, may each be found in persons of excellent 
health, at least such as are not actively tuberculous. This is because 
old and healed lesions, tuberculous and others, leave traces behind 
them which alter permanently the air content of the pulmonary par- 
enchyma and diagnostic methods in vogue disclose these conditions. 

Sources of Errors. — I am not prepared to state that the proportion 
of diagnostic errors made while attempting to recognize phthisis in its 
very incipiency is greater than in other diseases; in fact, I am convinced 
that it is not. But in phthisis, owing to its great prevalence and its 

l Jour, Am. Med. Assd., 1913., lx, 2027. 



INCIPIENT PHTHISIS 339 

social aspects, as well as its insidious onset, the opportunities for 
making mistakes are immense. It is for this reason that the sources 
of error must be emphasized. 

Bias is more often a source of error in phthisis than in any other 
disease. Especially is this the case when there is a history of exposure 
to infection. To my mind this is one of the greatest fallacies we have 
to cope with. It must always be remembered that in large industrial 
cities everyone is exposed to infection and is, in fact, infected with 
tubercle bacilli before he passes his fifteenth year. On the other 
hand, marital phthisis is less frequent than would be expected if every 
adult exposed to tuberculosis would become phthisical. Excepting 
in young children a case must therefore be judged on its clinical 
manifestations and not on the fact that the patient came into contact 
with a consumptive. 

Tubercle Bacilli. — The diagnosis of phthisis is clinched by the 
finding of tubercle bacilli in the sputum, but is not at all excluded by 
negatixe bacteriological findings. Unfortunately, too many wait rather 
long for the bacilli, thus losing valuable time which often cannot 
be reclaimed by any known means. Phthisis begins as an infiltra- 
tion, and only when softening has taken place and the products of 
tissue disintegration are eliminated through a bronchus, can tubercle 
bacilli be found in the sputum. Under the circumstances, waiting for 
tubercle bacilli, to make their appearance in the sputum is just as 
hazardous as waiting for pus to make its appearance through a fistula 
or sinus before making a diagnosis of a tuberculous joint. 

On rare occasions there are errors of quite a different nature. 
Tubercle bacilli may be found in the sputum of persons who are not 
actively tuberculous. Of course, from the practical standpoint tubercle 
bacilli in sputum are an indication that they are in all probability 
derived from a tuberculous lesion in the lower respiratory tract. But 
in New York City we meet with numerous persons who have reports 
from some private, as well as from the municipal laboratory, stating 
that the sputum of the bearer had been examined and found to con- 
tain tubercle bacilli. Yet, without any treatment or special care, they 
have kept at work for years and felt well. Indeed, many cases are 
admitted to sanatorium s solely on the strength of positive sputum 
findings, to be declared non-tuberculous after careful observation. 

The reasons for this anomaly are to be sought for in several facts 
which have not been emphasized as strongly as they deserve. I have 
no doubt that in busy laboratories mistakes are liable to happen in 
handling the sputum bottles, in numbering the slides, or while enter- 
ing the findings in the reports. In banks, where the clerks are just as 
careful as laboratory workers, mistakes occur at times. Even conced- 
ing that the number of such mistakes is comparatively negligible, in 
the individual cases it may count very much. 

We have already spoken of the acid-fast rods which simulate tubercle 
bacilli and which are found in butter and milk, on graminacea, in the 



340 CHRONIC PHTHISIS, INCIPIENT STAGE 

soil, in dung and manure, and even in tap water supplied through metal 
pipes. These bacilli are dead, or non-pathogenic to guinea-pigs, but 
they give the usual staining reactions. Then we may have the smegma 
bacilli which have been mistaken for tubercle bacilli and thus have 
led to erroneous diagnosis and extirpation of healthy kidneys. There 
are also the acid-fast lepra bacilli, the microorganisms which greatly 
resemble them and are found in the secretion of the mucous mem- 
brane of the nose, also the acid-fast rods found in the saliva, and the 
secretions in cases of bronchitis and pulmonary gangrene. L. Napo- 
leon Boston 1 found acid-fast bacilli in patients suffering from acute 
colds and influenza, and disappearing during convalescence. But 
most of these microorganisms are difficult to differentiate from tubercle 
bacilli microscopically, through culture and animal inoculation. 

It has recently been found that the spores of lycopodium are acid- 
fast, so that persons taking pills covered by that substance may impart 
some of it to the sputum and thus lead to error. 

There is a possibility that the acid-fast rods or specks found in the 
sputum may not have been there before it left the bronchial tubes and 
trachea, but got into the sputum while it was passing through the 
pharynx, mouth or lips, especially in persons living in houses inhabited 
by careless consumptives. I have repeatedly observed this to be a 
fact in consorts of tuberculous patients. Tubercle bacilli are found in 
the sputum — usually saliva — but they keep up in good health. It is 
also important, to mention that ordinary smear preparations are less 
likely to lead to errors of this sort than the antiformin method. 

To be sure, the most reliable sign of phthisis is tubercle bacilli in 
the sputum, and I do not at all intend to underestimate its far-reaching 
significance. Statistically, the chances of error are undoubtedly 
insignificant, and a laboratory may be proud that among several 
thousands of specimens, only half a dozen mistakes have been made. 
But the practising physician does not treat his patient statistically. 
In the individual case it is well to bear in mind the possibility of errors 
of this kind, especially in cases in which the disease does not pursue 
the corrse expected in some form of phthisis. 

Skiagraphy. — Skiagraphy has been discussed in detail in Chapter 
XVII. 

The Tuberculin Tests. — The changed reactivity to tuberculin which 
is observed in organisms infected with tubercle bacilli, manifesting 
itself mainly by hypersensitiveness to that agent, has been applied 
in the diagnosis of doubtful cases, especially in sanatoriums. When 
first introduced it was heralded as specific and it was asserted that 
finally a positive and uncontrovertible test had been found which 
decides whether or not an individual is suffering from active tuber- 
culosis. 

For diagnostic purposes, tuberculin is applied in various ways. It 

1 Interstate Med. Jour., 1914, xxi, 330. 



TUBERCULIN TESTS 341 

is introduced directly into the circulation by the subcutaneous method ; 
into the lymph spaces by the cutaneous method, or applied to mucous 
membranes for normal absorption by the conjunctival method. It 
has thus been applied to the skin, mucous membrane, and subcuta- 
neously. The subcutaneous application produces general and consti- 
tutional symptoms of tuberculin intoxication, while the others, as a 
rule, produce local effects. 

Clinically the following reactions are evoked by the tuberculin 
test: 

1. A general reaction, manifesting itself after the subcutaneous injec- 
tion of tuberculin by fever, chilliness, malaise, headache, backache, etc. 

2. A focal reaction, consisting in congestive and inflammatory 
phenomena in the neighborhood of the tuberculous lesion. 

3. Local reactions, hyperemia and inflammatory phenomena at the site 
of the tuberculin application. Of these there are : (a) The cutaneous 
reaction of von Pirquet and several of its modifications; (b) mucous 
membrane reactions, such as the ophthalmoreaction of Calmette and 
Wolff-Eisner, etc., and many others which have been discarded for 
valid reasons. \ 

The Cutaneous Tuberculin Test.— This is the simplest and unquestion- 
ably the harmless method of application of tuberculin for diagnostic 
purposes. It is usually performed on the inner surface of the fore- 
arm, though any part of the body may do, but it appears that the 
skin of the trunk is not so sensitive as that of the forearm and thigh. 
The skin is cleaned with alcohol or ether, and a drop of pure tuberculin 
is applied. A suitable instrument is then used to make two abrasions, 
one about two inches away from the spot where the tuberculin has 
been applied, and the other over the tuberculin. The instrument 
devised by von Pirquet may be used. It consists of a heavy handle 
with a spade-like platinum end which is more or less sharp and used 
for the purpose of scratching or boring a cup-like depression in the 
skin. It is important that bleeding should not be caused, but only 
the superficial layer of the skin is scraped away, so as to open the 
lymph spaces and thus favor absorption of the tuberculin. A needle 
may be used for the purpose or even the point of a scalpel, making one 
or two parallel incisions through the superficial layer of the skin. I 
have found it just as effective to make the abrasion first and then 
apply the tuberculin with a toothpick, rubbing it vigorously. After 
five minutes the excess of tuberculin is wiped away with some cotton 
and the patient allowed to go without any dressing. 

If the test turns out negative, it will be seen that twenty-four hours 
later the two abrasions either heal in the same manner, or when a 
scab is formed it is of the same appearance on both abrasions. When 
positive, the control appears healed, or showing a slight scab, while 
the abrasion to which tuberculin has been applied shows an inflam- 
matory infiltration manifesting itself as a slightly elevated, red papule. 
This reaction usually appears twelve to twenty-four hours after the 



342 CHRONIC PHTHISIS, INCIPIENT STAGE 

application of the tuberculin; on rare occasions it is premature, 
appearing within four to six hours, and may disappear soon, or remain 
for days; or it may be late in appearing; even a delay of a week has 
been observed in rare cases. 

The reaction may be slight, showing some redness with infiltration, 
or a more extensive area of redness with an appreciably raised papule. 
In some cases the red area is very extensive, simulating erysipelas and 
the papule is very elevated. Quite often the first test results in a 
negative outcome, but a second application, about a week later, gives 
positive results. It is therefore advisable to repeat the test two or 
three times before pronouncing it unequivocally negative. 

These "secondary" reactions are usually very intense, although the 
first application was negative. It has also been noted that the tuber- 
culin sensitiveness is often increased by a second or third inoculation 
and the area at which the first inoculation was made also reacts. 
Attempts to utilize these facts for diagnostic purposes have not been 
encouraging. 

Significance of the Cutaneous Tuberculin Reaction. — Clinical experi- 
ence has shown conclusively that persons who have at any time been 
infected with tubercle bacilli react to the cutaneous tuberculin test; 
experimental investigations have confirmed it. It is immaterial 
whether the infection is followed by clinical manifestations of disease 
or not; whether the tuberculous lesion is active or quiescent, the result 
is the same. It appears to me, however, that we do not have sufficient 
evidence for a conclusion as to the question how long after a lesion 
has healed does the skin remain sensitive to tuberculin. Assuming 
that no tuberculous lesion ever heals perfectly, which has not yet been 
proved, we accept that even healed lesions act in this way. 

Newborn infants never react to tuberculin, but when living in 
tubercle-laden surroundings they soon show the hypersensitiveness, 
as was already shown (page 64). Inasmuch as over 90 per cent, of 
humanity have been infected before reaching the twentieth year of 
life, we find that many show positive reactions to tuberculin. 

It is thus clear that for clinical purposes, when ive look for evidences 
of active phthisis, this test is of little value, because it shows not only 
those who suffer from active tuberculosis, but also such as have latent 
or healed lesions. Moreover, it is negative in rapidly progressing pul- 
monary tuberculosis, in tuberculous meningitis, in acute miliary tuber- 
culosis and also in the terminal stages of chronic phthisis, when the 
formation of antibodies is slackened or abolished. It has also been 
found negative in the presence of other infectious diseases, like measles, 
scarlet fever, diphtheria, etc., in some cases of pneumonia, and often 
during pregnancy. In a certain number of cases of undoubted phthisis 
the cutaneous reaction was found negative without any assignable 
reason; von Pirquet estimated it at from 2 to 4 per cent., but in my 
experience it is more than double that proportion. 

After many years of experience with this test it was concluded by 



TUBERCULIN TESTS . 343 

most authors that a positive cutaneous reaction is of clinical value 
only in children, and that the younger the child, the more its clinical 
significance. But from more extensive experience it appears that it 
is also unreliable in children. From personal experience I am inclined 
to the conclusion that children between three and fifteen years of 
age with a positive tuberculin reaction are not necessarily doomed to 
develop active phthisis; I have even observed many infants under 
two years of age grow into healthy children in spite of the positive 
outcome of the test, and the statement of some authors to the effect 
that an infant under one year showing a positive cutaneous reaction 
will not survive a year is negatived by the many infants I observed and 
reported elsewhere, 1 who have thrived despite the fact that during 
the first six months of their life the reaction was positive. 

Specificity of the Test. — It appears that from the scientific stand- 
point the specificity of the test has not been proved to the satisfaction of all, 
as has already been shown. Autopsy findings by Ganghofner, Rad- 
ziejewski, Behrend, Bruckner, Reuschel, and many others show that 
there are cases in which the test was positive, yet no tuberculous 
lesions were found at the autopsy, and the reverse. Experimentally 
the evidence is in the same direction (see p. 34). 

It has also been found that tuberculin is not the only substance 
capable of producing a positive skin reaction in tuberculous indi- 
viduals, but that other toxins when inoculated into the skin often pro- 
duce changes which are akin to the tuberculin reaction. Roily 2 found 
that the skin reacted when inoculated with the toxins of dysentery, 
typhoid, paratyphoid, pyocyaneous, cholera, etc. Just as with tuber- 
culin, these toxins were always negative in very young infants, and in 
children suffering from acute infectious diseases, as scarlet fever, 
measles,, etc., becoming positive during convalescence. The controls, 
performed with carbol-glycerin, were always negative. In short, these 
non-tuberculous toxins showed all the characteristics of tuberculin 
when inoculated into the human skin. That any or all of these toxins 
acted in an anaphylactic or specific manner may be ruled out because, 
with the exception of tuberculosis, the individuals tested never suffered 
from typhoid, paratyphoid, cholera, diphtheria or pyocyaneous sepsis. 
Tenzer 3 obtained skin reactions indistinguishable from those of the 
von Pirquet test with cholera vaccine and with a mixture of pepto- 
albumoses, in persons in whom the tuberculin test was positive. 

From these experiments, as well as from those performed by Sorgo, 4 
it appears that tuberculous individuals react with a specific intensity 
to tuberculin and to other toxins, thus indicating that it is mainly due 
to hypersensitiveness of the skin. The assumption that the skin of 

1 See A Study of the Child in the Tuberculous Milieu, Arch, of Pediat., 1914, xxxi, 
96, 197; 1915, xxxii, 20. 

2 Miinchen. med. Wchnschr., 1911, lviii, 1285. 

3 Monatschr. f. Kinderheilk., 1911, x, 131. 

4 Deutsoh. med. Wclnoschr., 1911, xxxvii, 1015. 



344 CHRONIC PHTHISIS, INCIPIENT STAGE 

the tuberculous is endowed with a specific allergy to tuberculin alone 
is thereby disproved. The allergy is evidently a cutaneous hypersen- 
sitiveness to the action of toxins in general. Hamburger, 1 one of the 
most authoritative champions of the specificity of the tuberculin 
test, after inoculating tuberculous patients with substances similar to 
those with which tuberculin is prepared (glycerin, bouillon, extractives, 
salts, etc.), became convinced that the cutaneous reaction is due more 
to the latter substances than to the tuberculin which acts merely as a 
skin irritant. 

We are therefore justified in concluding that we are far from having 
sufficient and satisfactory information to speak with certainty about 
the cutaneous tuberculin test and its underlying causes, and from the 
theoretical standpoint its specificity has not been proved conclusively. 

However, for demographers the test is important in showing the 
wide dissemination of tuberculous infection among civilized humanity, 
though the same results could be also obtained with substances other 
than tuberculin. In children it shows whether they have been infected 
with tuberculosis, and in infants it even points to active tuberculosis; 
but in adults it is of no clinical value at all. 

The various modifications of the cutaneous tuberculin tests are not 
superior to the von Pirquet method. The Moro test, consisting in rub- 
bing tuberculin ointment into the skin, is of less value than the one 
described above. The percutaneous, the quantitative cutaneous test, 
etc., offer no advantages over the von Pirquet test, which is after 
all the simplest and most reliable. 

The Conjunctival Reaction. — The conjunctival reaction, invented by 
Calmette and Wolff-Eisner, is made by instilling into the conjunctiva, 
with an ordinary eye-dropper, one drop of a 1 per cent, solution of 
tuberculin. The reaction appears within twelve hours and reaches 
its optimum in twenty-four hours, producing redness of the palpebra, 
and when the reaction is intense, the redness is more pronounced and 
there is also injection of the vessels of the eyeball and more or less 
well-marked secretion of mucus. It may last for two or three days. 
Of course, in estimating the effects of the tuberculin, comparison is 
made with the other eye. 

Among clinically non-tuberculous persons, from 10 to 25 per cent, 
react, while among those who are evidently tuberculous, between 50 
and 75 per cent, show a reaction with this test. It has been practically 
discarded of late because in many cases inflammatory phenomena 
have appeared in the tested eye which are quite troublesome. In 
one of my cases the inflammation was so severe, persisting for three 
months, that I have ever since hesitated in applying it. Bandelier 
and Ropke state that experiments on animals have shown that this 
test is unreliable in cases of human phthisis, since the reaction may be 
negative in spite of the presence of active tuberculosis unless 10 per 

1 Die Tuberkulose des Kindesalter, p. 37. 



TUBERCULIN TESTS 345 

cent, solution of tuberculin is used, and this should not be done when 
dealing with human eyes. 

The Subcutaneous Tuberculin Test. — This is the test preferred by 
most of those who have confidence in the diagnostic value of tuber- 
culin in doubtful cases. It is claimed that it is not only reliable in 
deciding whether the patient has ever been infected with tubercle 
bacilli, but also in showing whether the disease is active and that in 
many cases it even shows the area involved at the time the test is 
made by the so-called "focal reaction." 

Of the various ways in which it is performed, the following is the 
simplest and gives the same results as any that has been devised : 

For twenty-four hours the temperature of the patient is taken every 
three hours and carefully recorded. Inquiries are made as to the 
subjective symptoms, especially pains in the chest, headache, cough, 
expectoration, etc. An injection of 0.1 mg. of tuberculin is then made 
subcutaneously in the region of the back below the angle of the scapula, 
or any other place. Of course, all antiseptic precautions are to be 
rigidly observed and the skin washed with alcohol or ether. In case 
no reaction appears within forty-eight hours, a second injection is 
made with the same amount of tuberculin, while some increase it to 
1 mg. This dose is again increased in case no reaction follows to 5 
mg. and even to 10 mg. in case the test proves negative and a fourth 
injection is given. Of course, in children smaller doses are used. 

The Reaction. — Usually between ten to twelve hours, rarely between 
six to eight hours, in case the reaction is positive, constitutional, local, 
and focal symptoms make their appearance. Some say that it may 
be delayed as long as forty-eight to seventy-two hours, but this must 
be very rare; I have never encountered it. Of the constitutional 
symptoms, fever is the most constant and reliable. The temperature 
begins to rise six to twelve hours after the injection, reaching 100° to 
102° F., and in those showing a severe reaction, it may even go up to 
104° F., and I have seen several cases in which it was higher. There 
are usually constitutional symptoms of hyperthermia — headache, back- 
ache, pains in the joints, weakness, malaise and, in some cases, nausea 
and vomiting. Rarely the prostration is very pronounced, while in 
others it may be slight, or even absent, irrespective of the degree of 
fever. These symptoms usually subside within twenty-four to forty- 
eight hours and only rarely last longer. 

At the site of the injection the local reaction manifests itself in ten- 
derness or even pain, redness, and swelling, which may be small — only 
about 1 cm. — but in some cases the infiltration is as large as a hen's 
egg. Lymphangitis and enlargement of the regional lymphatic glands 
may occur. 

The so-called "focal reaction" is very rarely observed in phthisis. 
It is said to consist in congestion of the lesion in the lung, an increase 
in number and consonance of the rales, a change in the breath sounds 
and extension of the dull areas, accompanied by an increase in the 



346 CHRONIC PHTHISIS, ItfClPlMNf STAGE 

cough and expectoration. Tubercle bacilli hitherto absent from the 
sputum may now be found. My own experience leads me to the con- 
viction that this focal reaction is very unreliable. It occurs but rarely, 
and when we recall that in phthisis the physical signs change so often, 
and that a skilful clinician one day finds signs in one side and the next 
day in another without tuberculin injections, we may always suspect 
that the focal reaction is not necessarily a result of the tuberculin 
injection; at least its inconstancy should lead us to this conclusion. 

Clinical Value of the Test. — The object of the test is to clear up doubt- 
ful cases in which there are symptoms and signs pointing to active 
phthisis but which are not convincing to clinch the diagnosis. In such 
cases the advocates of the test claim that a positive reaction decides 
in favor of active disease, while a negative outcome decisively excludes 
it. It has been used mostly in sanatoriums for these purposes. 

Careful analysis of the conditions under which this test is negative 
or positive shows that it is hardly of greater reliability than the cuta- 
neous or conjunctival test. Investigations by Franz, 1 Hamman and 
Wolman, 2 Beck, 3 and many others show that it may be positive in 
healthy persons who do not develop phthisis subsequently. The 
experience of all who have applied this test to large numbers of actually 
or apparently non-tuberculous individuals is the same as that of Franz, 
Hamman and Wolman, Beck, etc. 7/ is always found that between 40 
and 60 per cent, of humanity react to the subcutaneous tuberculin test, 
providing it is repeated with ascending doses three or four times. 

Specificity of the Test. — We have already mentioned that many non- 
tuberculous substances have a toxic action on the organism infected 
with tubercle bacilli. Thus, according to experiments by Mettetal, 4 
Preisich and Heim, 5 Petruschky, 6 and many others, nucleins, blood- 
serum, testicular extract from healthy animals, culture-free bouillon, 
and other foreign albumoses, when injected into tuberculous persons, 
may provoke reactions not unlike the general reaction of tuberculin. 
It appears that the tuberculin reaction is part and parcel of the hyper- 
sensitiveness of the infected organism to foreign proteins of any kind, 
tuberculous and non-tuberculous (see p. 34). 

Diagnostic Value. — Considering that the subcutaneous tuberculin 
test discloses latent infection, as well as active tuberculous disease, 
its diagnostic value is limited, bearing in mind that over 90 per cent, 
of humanity have been infected at some period of their lives. What 
we look for is active disease and when the test also shows those who are 
not phthisical, its value in diagnosis is limited indeed. 

"A positive tuberculin reaction," say Hamman and Wolman, "is 

1 Wien. klin. Wchnschr., 1909, xxii, 991. 

2 Tuberculin in Diagnosis and Treatment, New York, 1912. 

3 Deutseh. med. Wchnschr., 1899, xxv, 137. 

4 Valeur de la tuberculine dans le diagnostic de la tuberculose de la premiere enfance, 
These de Paris, 1900. 

s Zentralbl. f. Bakteriol., 1902, xxxi, 712. 

6 Ergebn. d. Inn. Med. u. Kinderheilk., 1912, ix, 557. 



THE COMPLEMENT-FIXATION TEST 34? 

merely confirmatory evidence and never decides with certainty an 
otherwise doubtful diagnosis. Indeed we feel that caution is decidedly 
in place not to lay too much emphasis upon a positive reaction, for if 
a patient is suffering from symptoms which may be accounted for by 
a number of different conditions, and by applying the test we admit 
such uncertainty, a positive reaction does not impel the conclusion 
that these symptoms are due to tuberculosis. If such a large percen- 
tage of healthy individuals harbor clinically unimportant tuberculous 
lesions, a certain proportion of those suspected of having tuberculosis 
must likewise harbor them, though the symptoms that attract our 
attention may be due to some other disease." With this view the 
present writer agrees entirely. How far the tuberculin test has been 
discarded as a diagnostic agent is seen from the fact that in none of 
the armies engaged in the World War has it been adopted as a test 
for active tuberculous disease, though all efforts have been made to 
weed out tuberculous persons from the service. 

Dangers of the Test and Contraindications. — The subcutaneous tuber- 
culin test is not without dangers. When carelessly performed with 
excessive doses, latent or quiescent lesions may be flared up into 
activity. Recently, L. Rabinowitsch, 1 Bacmeister, 2 Leo Kessel, 3 and 
others have shown that living and virulent tubercle bacilli may appear 
in the blood after an injection of tuberculin. In some cases it has been 
observed that hemoptysis is provoked by the test, and all agree that 
it must not be given during, or soon after, a pulmonary hemorrhage. 
In general the reaction consists essentially in a transient toxic 
injury to the body, and the nervous system bears the brunt of the 
traumatism. 

It has also been found dangerous in cases of heart disease, arterio- 
sclerosis, nephritis, diabetes, etc. In epileptics it has been observed 
that the reaction may provoke convulsions. Even Bandelier and 
Ropke say that it is contraindicated when miliary tuberculosis is sus- 
pected " since its downward course might be accelerated." Sahli, 4 who 
uses tuberculin for therapeutic purposes extensively, says: "The use 
of tuberculin for diagnostic purposes ought to be condemned. It is 
unreliable both positively and negatively. Diagnostic injections are 
dangerous." 

The Complement-fixation Test. — Quite recently the complement- 
fixation test on the lines of the well-known Wassermann reaction for 
syphilis has been applied in the diagnosis of tuberculosis. It has been 
studied by Besredka and Manoukhine, 5 Calmette and Massol, 6 Debains 
and Jupille, 7 in France, and in England by James Mcintosh, Paul 

1 Berl. klin. Wchnschr., 1913, 1. 2 Munchen. med. Wchnschr., 1913, Ix. 

3 Am. Jour. Med. Sc, 1915, cl, 337. 

4 Fifth Confer. Nat. Assn. Prev. Consumption, London, 1913, p. 57. 

5 Ann. de l'Inst. Pasteur, 1914, xxviii, 569; Compt. rend. Soc. de Biol., 1914, lxxvi, 
197. 

6 Ann. de l'Inst. Pasteur, 1914, xxviii, 338. 

7 Compt. rend. Soc. de Biol., 1914, lxxvi, 199. 



348 CHRONIC PHTHISIS, INCIPIENT STAGE 

Fildes, 1 J. A. D. Radcliffe and Edward Glover. 2 In this country, J. 
Bronfenbrenner, 3 A. M. Stimson, 4 Charles F. Craig, 5 H. R. Miller, 
and others have reported good results with this test. 

But so far the results appear to be conflicting in certain points, so 
that further careful research, combined with clinical observations are 
necessary before deciding on the specificity and clinical applicability 
of the test in general practice. The main difficulty is evidently the 
fact that different authors have used different antigens. Besredka 
used one prepared from egg-broth cultures of tubercle bacilli; Rad- 
cliffe used a freshly prepared unsterilized emulsion of saline solution 
of living tubercle bacilli grown on glycerin-egg medium; Hammer 
used an alcoholic extract of tuberculous tissue to which was added a 
certain amount of old tuberculin; Stimson and Bronfenbrenner use 
Besredka's antigen; Craig's antigen consists in an extract of several 
strains of human tubercle bacilli prepared by a special method. It 
is thus clear that with so many different methods, the results are 
hardly comparable. Moreover, as Mcintosh points out, Besredka's 
antigen cannot be considered absolutely specific since Inman and 
Ktiss and Leredde and Rubinstein found that non-tuberculous syphili- 
tics gave the reaction frequently. Even if the explanation that it is 
due to the lipoids derived from the egg constituents of the medium, 
which react with the syphilitic serum in a manner similar to tissue- 
extract antigen, is correct, it does not help us in our efforts to find a 
specific test for active tuberculosis. 

Various authors report between 40 and 95 per cent, of positive 
results with the complement-fixation test. Some state that a positive 
reaction means an active tuberculous process somewhere in the body. 
Mcintosh and Fildes state even that a small lesion may not reveal 
itself by this test; "the lesion must be of considerable dimensions 
before the reaction can detect it. A caseous bronchial gland will not 
give a positive reaction; indeed, the common affection of the cervical 
glands will usually yield a negative result. On the whole, we have 
come to the conclusion that a lesion in order to give positive results 
must be of such dimensions as to constitute 'disease' and require the 
intervention of the physician or surgeon. We look upon the positive 
reaction, therefore, as indicating 'active tuberculosis.' " On the other 
hand, Craig found that 65 per cent, of clinically inactive cases of pul- 
monary tuberculosis gave positive reactions. Most writers obtained 
positive reactions in patients with syphilis. 

This test has been given an extensive and careful trial in my wards 
at the Montefiore Hospital. My associate, Dr. H. R. Miller, has applied 
it in a very large number of cases. But I have not been impressed with 
its reliability as a diagnostic agent when we attempt to discriminate 

1 Lancet, 1914, ii, 485. 2 Quarterly Jour, of Med., 1915, viii, 339. 

3 Arch. Int. Med., 1914, xiv, 786; Proc. Soc. Exper. Biol, and Med., 1914, xii, 48. 

4 Bull. 101, Hyg. Laborat., U. S. P. H. S., 1915. 
* Am. Jour. Med. Sc, 1915, el, 781. 



THE COMPLEMENT-FIXATION TEST 349 

between tuberculous infection on the one hand and active tuberculous 
disease on the other. In many active cases it has been negative, while 
many non- tuberculous cases showed positive results. It appears to be 
of about the same value as the von Pirquet skin reaction. It, as a rule, 
discloses infection. To discover infection, the skin reaction may be 
applied with less trouble. B. Stivelman, who reports a large number 
of cases from the Bedford Sanatorium, arrives at the same con- 
clusion. 

Other Special Tests. — Most of the other special diagnostic tests 
which have been brought forward from time to time have been found 
wanting in reliability; their limitations preclude their general adop- 
tion. Arneth's blood-picture has never been considered of diagnostic 
value and was only urged as of prognostic significance (see p. 244). 
Wright's opsonic-index method has been given a very extensive trial, 
especially in English-speaking countries, but has been found unreliable. 
The results are very conflicting and the method is altogether unsuit- 
able for general adoption. 



CHAPTER XX. 
CHRONIC PHTHISIS. ADVANCED STAGE. 

Duration of the Incipient Stage. — Incipient phthisis is also called 
"early" phthisis, and thus confusion is engendered in the minds of the 
laity, as well as of physicians, who assume that a case is incipient only 
for a certain time and then progresses to the second or third stage, 
unless properly treated. This is wrong. There are cases which are 
"advanced" soon after the active symptoms manifest themselves, while 
others, though remaining active for years, never pass beyond the stage 
of incipiency. Indeed, we meet with many patients who have been 
tuberculous for many years, and have been admitted to sanatoriums 
several times as "early" cases. 

The sagacious clinician, Laennee, stated nearly one hundred years 
ago that it appeared to him that hardly any consumptive succumbs to 
the first attack of the disease, and that in the vast majority of cases 
the first attack is erroneously diagnosticated as a mild respiratory 
trouble. The disease then remains latent for a longer or shorter time 
to break out again, perhaps with greater severity. Many years of 
research along scientific lines have confirmed Laennec's observation. 
A large number of cases never become " advanced" in the sense we use 
this term. Others show greater activity, and the process in the lungs 
proceeds from infiltration to caseation, softening and excavation within 
six months or a year. A large proportion of active cases remain 
quiescent for one or two years, and then suddenly take a turn for the 
worse and the patient sinks, succumbing to exhaustion or to some 
complication. 

On the whole it may be stated that in the clinical sense, "incipiency ' 
does not necessarily imply earliness of the process. It means a limited 
and curcumscribed lesion which is not manifesting a tendency to acute 
progression, but either remains quiescent or leans to cicatrization of 
the lesion. In this stage the patient may remain for many years and 
no average duration can be assigned. It can only be estimated in the 
individual patient, depending as it does on so many different and com- 
plex factors which have been discussed elsewhere in this book. 

Course of Incipient Phthisis. — In a large proportion of cases phthisis 
does not pass beyond the so-called stage of incipiency. The patient 
coughs, expectorates, has fever, hemoptysis, etc., for several weeks or 
months, and, after taking a rest in the country, spending a few months 
in a sanatorium, or even while continuing at his occupation, he slowly 
recuperates and recovers, never to be troubled again with pulmonary 



COURSE OF CHRONIC PHTHISIS 351 

symptoms. In most of these cases there are left remnants of the pul- 
monary lesion in an apex, manifesting themselves in impaired resonance, 
prolonged expiration and sibilation. This conforms to the abortive 
type of tuberculosis which will be discussed later on (Chapter XXIII) . 

But in many cases the disease progresses steadily, especially when 
no proper treatment has been instituted, and occasionally irrespective 
of the treatment. In a small proportion of cases the progress is rather 
rapid, and within one or two months after the first symptoms have 
appeared, the patient is a confirmed consumptive; while in others the 
course is slower, the patient keeps on coughing, expectorating, losing 
flesh and strength for several months or years, when a change takes 
place and he is apparently improved or cured, or he succumbs to the 
disease. 

In the vast majority the progress of the disease is marked by dis- 
tinct remissions, during which the patient feels comparatively well, 
is able to pursue his vocation, and he, as well as his physician, is 
under the impression that a permanent cure has been attained, to be 
undeceived, now and then, by the appearance of an acute exacerbation 
of the disease during which the patient is laid up for several days or 
weeks, or by a pulmonary hemorrhage, which may or may not be 
copious; an attack of pleurisy, with or without effusion, etc. 

There is another class of cases in which the focus in the lung remains 
quiescent, but does not cicatrize for many years. Physical examina- 
tion of the chest shows distinct signs of an active pulmonary lesion 
and an examination of the sputum may even disclose tubercle bacilli, 
but the symptomatology and course are benign — the cough is mild, 
there are no fever, no nightsweats, no emaciation, and the patient is 
capable of working at his vocation for years. These may be considered 
"carriers." Though harboring tubercle bacilli in their lungs, and 
disseminating them with the sputum, they are themselves fairly 
healthy. 

Oscillating Course of Chronic Phthisis. — A continuous course from 
bad to worse till the patient dies, or with improvement till he recovers, is 
uncommon in chronic phthisis. It is characteristic of either the abortive 
form of phthisis, on the one hand, or of acute galloping phthisis,. on the 
other. But the usual case of chronic phthisis pursues a discontinuous, 
paroxysmal, I may say a capricious course, marked by periods of acute 
or subacute exacerbations of the symptoms, and periods of remissions 
during which the patient is more or less free from the troublesome symp- 
toms, or he may even feel comparatively well, working efficiently, 
especially if he is engaged in some intellectual pursuit. I have seen 
many who have worked at hard manual labor for months until an 
acute exacerbation laid them up for several weeks, but they sooner or 
later recuperated and went to work again, until another acute exacer- 
bation interfered. 

These acute exacerbations during the course of chronic phthisis 
usually have distinct pathological substrata. In active phthisis the 



352 CHRONIC PHTHISIS— ADVANCED STAGE 

affected part of the lung caseates, softens and is finally eliminated by 
cough and expectoration, leaving a fistula to drain the excavation 
which is surrounded by a fibrous capsule that inhibits or prevents 
absorption of toxic matter. The patient may feel comparatively well 
so long as the cavity in the lung is well drained. But now and then the 
fistula is obstructed, or a new area becomes involved by contiguity or 
metastasis, and again acute symptoms of constitutional toxemia make 
their appearance. This acute exacerbation keeps on for some time till 
either the fistula opens again, or the newly involved area has softened, 
the products of tissue disintegration are eliminated, and the patient 
feels well again, though he is by no means cured. 

This undulating course of phthisis can be clearly observed by study- 
ing the temperature, expectoration, emaciation, etc., of the patients, 
as was done by Bezancon, 1 Serbonnes, 2 and others. It may keep on 
for many years. In most cases one of two things finally occurs — either 
the infiltrated or excavated area in the lung cicatrizes, or becomes 
encapsulated and shrinks and the disease is arrested; or, during one 
of these exacerbations, the pulmonary involvement becomes too 
extensive, and can no more become quiescent and, with or without 
some complication, the patient succumbs. 

We may say that during the long course of chronic phthisis there is 
an intense struggle between the bacilli and the resistance of the host. 
We have seen that everybody possesses more or less resistance; else 
every infection would speedily prove fatal. In this struggle the bacilli 
gain the upper hand for a time and cause an acute exacerbation, but 
the innate resistance is again called upon and usually responds, the 
result being a truce, until the bacilli again catch the organism napping. 
The final outcome depends on many and complex factors which are 
discussed elsewhere. 

Symptoms. — The cough, which may have been mild during the 
incipient stage, gradually becomes more and more annoying and 
productive. It may be painful, paroxysmal and exhausting, and end 
in vomiting, especially after the evening meal. But with the advance 
of the process the cough is ameliorated in most cases; while it does 
not cease altogether, it becomes " looser;" the sputum is brought up 
without great effort. During acute exacerbations it is usually aggra- 
vated, often painful, due to complicating dry or moist pleurisy, etc. In 
some cases the cough is mild throughout the course of the disease, while 
in others it constitutes the main complaint of the patient. In fatal cases 
it may be absent during the last few days of life, when the reflexes are 
abolished, or, because of severe emaciation and muscular atrophy, the 
patient has not enough strength for the efforts at coughing. 

The mucoid sputum of the incipient stage becomes more and more 
mucopurulent with the advance of the disease, and almost invariably 
contains tubercle bacilli. Exceptionally, none are found in a case 

1 Paris medical, 1911, p. 133. 

2 Les Poussees evolutives de la tuberculose pulmonaire chronique, Paris, 1910. 



SYMPTOMS OF CHRONIC PHTHISIS 353 

that keeps on progressing, even to fatal issue. But this is exceedingly 
rare. Elastic fibers are, however, found in practically all cases in which 
the disease has passed incipiency, owing to the destruction of lung tissue 
during caseation and liquefaction. Immediately before and during an 
acute exacerbation the amount of sputum may be diminished, but 
within a few days it again increases in quantity. With the disinte- 
gration of lung tissue and formation of vomicae, the character of the 
sputum changes; it becomes thick, nummular and sinks in the water 
of the receiving vessel. During hemorrhages it is sanguineous, and 
often without any evident hemorrhage it is tinged with blood. During 
quiescent periods the amount expectorated is, as a rule, diminished; it 
may lose its purulent character and, when a cure is established, the 
expectoration may cease. In fatal cases we often note that during the 
last few days little sputum is brought up. The patient has not sufficient 
strength to expel it, as has already been mentioned. 

The temperature in active advanced cases is not of a characteristic 
type. In progressive cases it may be continuous or remittent till 
the end — recovery or death. Usually the curve, when studied for 
several months continuously, pursues an undulating or cyclic course. 
For several weeks it is high, no matter what type it is, rising to 101°, 
or even 104° F. in the afternoon, and declining several degrees in the 
morning, in many cases even to a subnormal degree. Slowly an 
improvement is noted, the temperature becomes lower and lower and 
we may find a period of either subfebrile or even normal temperature 
for a few weeks. In many cases I have noted a subnormal tempera- 
ture for comparatively long periods. 

But suddenly — perhaps after a chill or some indiscretion — or grad- 
ually, the temperature rises again and keeps at a high level for several 
days or weeks, thus marking an extension of the process to a hitherto 
unaffected area of the lung, or some complication. 

It is noteworthy that during the afebrile periods the patient feels 
quite well and, for weeks, may consider himself cured, to be sadly dis- 
appointed during the acute exacerbations which are sure to come in 
most cases. Even during febrile periods many feel comparatively 
well and have a good or fair appetite, as was already stated. The 
intellect is usually clear; those engaged in intellectual pursuits may 
follow their vocations during the exacerbations. I have had patients 
who did business on a high scale under such circumstances, and writers 
and artists who produced their best work while the thermometer 
registered 103° F. The euphoria, which is characteristic of phthisis, is 
best observed in far-advanced cases. 

Emaciation goes hand-in-hand with other constitutional symptoms, 
especially fever. Those who have no quiescent periods lose flesh very 
rapidly, and within a few months may be reduced to mere skeletons. 
In those in whom the disease runs an undulating course, we often 
note a gain in weight during afebrile periods, and if the fever is mild 
during acute exacerbations and of short duration, the loss in weight 
23 



354 



CHRONIC PHTHISIS— ADVANCED STAGE 



may be insignificant. They may be ahead in this regard at the end 
of a year or two, although the process in the lungs remains stationary, 
or has even progressed. 

Toward the end the emaciation is very pronounced and deserves 
the name consumption. Then it is not only the fever, cough, and 
expectoration that are exhausting the patient, but also the lack of 
nourishment owing to anorexia, diarrhea, and perhaps dysphagia when 
the larynx is implicated. The preservation of the body weight, which 
is very frequent in fibroid phthisis, is only rarely seen in chronic 
phthisis, and, when found, it is an indication of improvement, or that 
the quiescent periods are of long duration. 




Fig. 62. — The phthisical or flat chest. Habitus phthisicus. 



Hemoptysis is comparatively infrequent during this period, except- 
ing in very advanced cases with cavities, when a terminal hemorrhage 
may carry off the patient, and in those suffering from hemorrhagic 
phthisis (see p. 207) it may recur at irregular intervals. As was 
already stated, most of the hemorrhages at this period, even when 
profuse, end in recovery. 

The other symptoms of chronic phthisis have already been described 
in detail in previous chapters. 

Physical Signs. — Depending on alterations in the pulmonary 
parenchyma, pleura, mediastinum and chest walls, the physical signs 
of advanced phthisis are complex. By percussion and auscultation 



PHYSICAL SIGNS OF CHRONIC PHTHISIS 355 

we may determine, with a reasonable degree of certainty, the nature 
of the lesion, as well as the condition of the apparently unaffected 
parts of the thoracic viscera. But with the progress of the disease, 
the changes found on physical exploration become more and more 
variegated and, owing to frequent overlapping of pathological changes, 
their complexity is so great that it is often quite difficult or impossible 
to determine exactly the details of these changes by physical examina- 
tion. This is well illustrated by the difficulty of differentiating pleural 
adhesions before inducing a therapeutic pneumothorax, and by the 
number of cavities that are missed during life and found at necropsy. 
Radiography is of immense value at this stage, but it is not infallible, 
as has already been shown. 

Percussion. — The tuberculous infiltration usually extends in hori- 
zontal planes; metastatic deposits of tubercle at a distance from 
the original focus in the same or the opposite lung are only rarely 
found. The result is that the impairment of resonance found over one 
apex during the incipient stage extends mainly downward, and, in 
progressive cases, we soon find dulness as far as the third or fourth rib, 
or lower. The pitch of the note depends on the density of the infil- 
tration, on the presence or absence of excavations, the amount of 
secretions in the cavity, and on the condition of the pleura. On the 
unaffected side a hyperresonant' note may be elicited, which may be 
accentuated by vicarious emphysema. 

Dulness is very frequently found in the interscapular spaces which 
may be an expression of enlarged peribronchial glands, or infiltration 
of the apex of the lower lobe of the lung. In the majority of cases 
there is more or less retraction of the base of the lung, easily made 
out by tidal percussion. 

With percussion we may also determine the position of the heart 
which in many cases is of immense diagnostic significance, as has 
been pointed out elsewhere by the writer. 1 In phthisis the heart is, 
as a rule, dislocated toward the affected side, the reverse of conditions 
found in pleural effusions, pneumothorax, etc. It is therefore impor- 
tant to determine the position of the heart in cases showing intense 
dulness of the lower parts of the chest on one side when the problem 
arises whether it is due to an effusion, or to thickened pleura with 
pulmonary retraction. Exploratory puncture, if negative, is not con- 
clusive, but when we find the heart displaced to the opposite side, 
we may conclude that there is an effusion, while when it is dislocated 
toward the affected side, it is due to excavation and to pleural thick- 
ening. But to this there are many exceptions which are discussed 
elsewhere. 

The routine methods of physical exploration show the location of 
the heart in phthisis easily and vividly; but in many cases the diag- 
nosis is difficult and occasionally almost impossible. The side of the 

1 Arch. Int. Med., 1914, xiii, 656. 



356 CHRONIC PHTHISIS— ADVANCED STAGE 

heart adjoining the healthy lung is easily made out by percussion, but 
the cardiac dulness at the side adjoining the affected lung merges 
with the dulness of the infiltrated and consolidated lung tissue or thick- 
ened pleura, and it is difficult to separate by any method of percussion. 
The fluoroscope and the skiagraphic plate also fail at times to show a 
definite outline of the borders between the heart and the lung. Indeed, 
I have found at times that orthodiagraphy was of no avail. 

Dextrocardia is not rare in extensive right-sided lesions. It is to be 
differentiated from complete transposition of the viscera by the loca- 
tion of the liver, spleen, etc. 

Auscultation. — Auscultation in advanced phthisis is of even greater 
diagnostic significance than percussion and skiagraphy, because it 
shows distinctly the progress of the process in the lungs, especially 
its activity. The diagnosis of a healed lesion can only be made by a 
study of the constitutional symptoms and a careful consideration of 
the auscultatory phenomena elicited over the chest. 

The brea th sounds which, during the incipient stage, may have been 
somewhat altered, rough, cog-wheel or feeble, now become more and 
more bronchial or tubular in character. Excepting in very acute cases, 
which do not concern us here, bronchial breathing does not appear 
suddenly in chronic phthisis. Following a progressive case we may 
observe that the cog-wheel breathing changes by degrees; first the 
expiratory murmur becomes prolonged, then the sounds assume a 
bronchovesicular character, indicating that the breath sounds are 
mixed, the vesicular coming from the healthy lung and the bronchial 
from the disseminated infiltrated patches. When these patches con- 
glomerate, and the part of the lung consolidates into an extensive 
airless area, thus acting as a good conductor of the laryngotracheal 
murmur to the surface, we get bronchial breathing. With the onset 
of softening the products of tissue disintegration are expelled, leaving 
an excavation and we often, though not invariably, hear cavernous 
or amphoric breathing, which will be discussed later on. 

The advance of the lesion is characterized pathologically by soften- 
ing of lung tissue, followed by liquefaction and cavity formation. 
These changes are best determined by auscultation and the detection 
of moist rales which are produced by the air current passing from 
the bronchi into the diseased area filled with debris of disintegrated 
tissue. These rales are of various sizes — large, medium or small — 
according to the size of the bronchus, or the excavation in which they 
are produced. Usually they are consonating, ringing and either pro- 
voked, or intensified, by cough. Their diagnostic significance lies 
mostly in their localization and persistence. They are mostly found 
over the supraspinous fossae, in the upper part of the interscapular 
space, and especially above and below the clavicle, and with them we 
usually hear low-pitched, bronchial breathing. When heard unilater- 
ally and persistently in any of these locations, they are, with but few 
exceptions, pathognomonic. 



CAVITIES 357 

The onset of softening is characterized by the appearance of moist 
rales, usually small or of medium size. They have been called by the 
French rales de friture because they simulate the sounds heard when 
frying something. But we must guard against overestimating the 
extent of the disease by wide distribution of rales. With concomitant 
bronchitis they may be distributed all over the chest, or all over one 
hemithorax, while the tuberculous lesion is rather limited. After 
pulmonary hemorrhages the rales are heard far away from the tuber- 
culous area, and we must be guarded in concluding that it is an 
indication of widespread extension of the tuberculous lesion. The 
thermometer is a better guide under such circum stances. 

On the whole, it can be stated that the activity of the tuberculous 
process may be gauged by the number, character, and distribution of 
moist rales audible over the chest. The larger their number, the larger 
their consonance, when localized over a limited area, the more active 
the process, while absence of rales, coupled with absence of con- 
stitutional symptoms, indicates an arrest in the progress of the 
disease. 

Sibilation is quite frequently heard in cases of advanced phthisis 
and it may be caused by various conditions. In the interscapular 
spaces, and near the two sides of the sternum, whistling sounds are 
an indication of tracheobronchial adenopathy with pressure on the 
bronchi. In some cases, we hear sonorous rales all over the chest, or 
unilaterally, in cases complicating bronchitis or emphysema; over 
areas of localized vicarious emphysema, sibilation is also heard at 
times. For a long time, or permanently, after a lesion has healed, there 
may remain sibilation, "cicatricial rales." 

Friction sounds are very frequently heard. Their significance is 
discussed in connection with pleurisy. 

Cavities. — This stage is characterized by the formation of pulmonary 
excavations. The constitutional symptoms accompanying the forma- 
tion of cavities depend on the acuteness of the process. So long as 
the excavation is surrounded by infiltrated and caseated lung tissue, 
the symptoms are acute — high fever of a continuous, or remittent 
type, profuse nightsweats, severe cough with abundant expectoration, 
rapidly progressing emaciation, etc. But in most cases the process 
is not so acute. The excavation is surrounded by a fibrous shell which 
limits its progress, and prevents absorption of the toxic products to 
a great extent, so that the patient may feel quite well despite the 
formation of more or less extensive excavations in his lungs. In the 
chronic cases that do not succumb, but do not heal either, the cavity 
may keep on secreting mucopurulent matter which is promptly 
removed through the fistulous tract that leads to a bronchus. 

It is in these chronic cavitary cases that we meet the undulating 
clinical picture of phthisis described above. Whenever the fistulous 
tract leading from the cavity is obstructed, the amount of expectora- 
tion is diminished and fever, nightsweats, etc., result, till the plug in 



358 CHRONIC PHTHISIS—ADVANCED STAGE 

the bronchus is dislodged, when expectoration begins to drain the 
cavity and the patient again feels comparatively well. 

Diagnosis of Cavity in the Lung. — If we should accept the signs given 
in text-books as infallible criteria, the diagnosis of cavities is very 
simple. But those who often make autopsies and have opportunities 
to verify their findings are frequently amazed at the large number of 
cavities found intra vitem, but missing at the autopsy, and the reverse. 

In order that a cavity should be discerned by physical explora- 
tion, or even by skiagraphy, it must attain the size of at least four 
centimeters in diameter; it must be superficially located, filled with 
more air than secretions and communicate with a bronchus. In the 
apex cavities are often missed because the thick, indurated pleura 
screens all signs. Some even maintain that they must have smooth 
walls if we are to elicit by auscultation and percussion the signs which 
are characteristic of excavations. In fact, many authors who have 
studied the physical signs of vomicae, verifying their findings at 
necropsies, found that many excavations are overlooked, while others 
that are diagnosed are not found at the autopsy. For this reason some 
believe that the presence of elastic tissue in the sputum is the best sign 
of pulmonary excavation. 

Inspection and palpation are of little value. The muscular atrophy 
noted over deep excavations above and below the clavicle may be 
seen in pulmonary retraction without excavation. Over superficial 
cavities, extreme atrophy of muscles and integuments of the area 
overlying the excavations is very frequent. This atrophy leaves the 
chest wall over a circumscribed area very thin and, combined with 
pleural adhesions and retraction, may cause a cup-shaped depression 
localized over the site of the cavity, which is pulled in during inspira- 
tion. But this is comparatively uncommon, probably because many 
cavities are situated deeply within the lung. 

Percussion over a cavity gives a dull note, and only over large exca- 
vations, superficially located in the infraclavicular region of emaciated 
patients, and filled mostly with air, may be obtained a hyperresonant 
or tympanitic note. At most, we usually find dulness with a tympanitic 
overnote. But to indicate excavation, even this must be strictly 
localized and circumscribed. The resonance may change within a 
single day from tympany to dulness when it fills up with secretions. 

On the whole, cavitary tympany depends on many factors. In 
young persons, with elastic and resilient chest walls, it is more often 
present over small excavations than in the aged, whose chests are 
usually rigid and unyielding, and even large excavations may not be 
tympanitic. The more superficial the location, the more pronounced 
the tympany, while deeply lying cavities are screened by air con- 
taining lung tissue and tympany is altogether absent. It is thus 
evident that tympany is not a constant sign of cavitation, but when 
localized, circumscribed and pronounced it speaks for a cavity of 
large size with greatly relaxed walls; and conversely, we find high 



CAVITIES 350 

tympany over tight walls of small cavities. It may best be perceived, 
as Flint showed long ago, when the ear is close to the patient's mouth, 
or when the bell of the stethoscope is held in this position. Cracked- 
pot resonance is also best perceived in this manner. 

The most common site of tympany due to cavitation is above the 
fourth rib anteriorly, and on rare occasions we find it in the axillary 
line beneath the fifth rib, especially in the left side, while posteriorly 
it is exceedingly rare because of the large muscles which interfere with 
percussion. I have met with cavities that were tympanitic over three- 
fourths of the chest wall, indicating excavation of almost an entire 
lung. But this is rare because in such cases the mediastinum is pulled 
over and produces dulness. 

Occasionally the tone changes known as Wintrich's, Friedreich's and 
Gerhardt's phenomena are of assistance in the diagnosis of vomicae, 
but not so frequently as some text-books would lead us to believe. 

Wintrich's phenomenon, obtained by percussion while the patient 
opens and closes his mouth, the note being tympanitic when it is 
open, and of lower and deeper pitch when closed, is a good indication 
of a cavity communicating with a bronchus and is. more distinct the 
greater the diameter of the bronchus. It may be obtainable only in 
certain positions of the body (interrupted JVintrich), which is clearly 
due to the presence of fluid secretions within the cavity which obstruct 
the opening of the bronchus. It is also met with in some cases of 
bronchiectatic excavations, but this is to be distinguished by the 
location of the cavity — anteriorly and above in tuberculosis, and 
posteriorly and below in bronchiectasis. Tt may also be found in 
pneumothorax, but the concomitant symptoms and signs clear up 
the diagnosis, excepting in the localized and latent forms, which can 
only be recognized with the x-rays. 

William's tracheal tone, observed while percussing the consolidated 
apex which conducts the tracheal tympany, is at times mistaken for 
Wintrich's phenomenon. It is usually found in cases of contraction 
or consolidation of lung tissue, or its compression in pleuritic exudates, 
when percussion above and below the clavicle sets up vibrations in 
the main bronchus and the trachea. 

Friedreich's phenomenon consists in high-pitched tympany over the 
site of excavations when the patient holds his breath during full inspira- 
tion, diminishing during extreme and held expiration. This is not so 
reliable as Wintrich's sign because it is at times obtained over healthy 
lungs. 

In Gerhardfs phenomenon the note is higher and more tympanitic 
when the patient is sitting or standing than when he is reclining, and 
is said to be characteristic of an oval-shaped cavity filled partly 
with fluid and partly with air, the fluid gravitating according to the 
position of the patient. Small cavities, superficially located, occasion- 
ally show this sign and when the excavation is centrally located, it 
must attain considerable dimensions to be thus characterized. As 



360 



CHRONIC PHTHISIS— ADVANCED STAGE 



Sahli points out, Gerhardt's phenomenon is rare, and slight differences 
in the percussion note with changes in position may be within physio- 



Gerhardt's phenomenon 
Stethoscope 



Interrupted Wintrich's 
phenomenon 



Stethoscope 



Biermer's phenomenon 
coin-percussion 




Coin 



Coin 



= shaded = fluid 
Clear space = air 



Fig. 63. — Illustrating Gerhardt's and Biermer's phenomena, interrupted Wintrich's 
phenomenon and coin-percussion. (Musser.) 

logic limits due simply to alteration in the tension of the thoracic 
walls without any cavity within the chest. 



Interrupted 
Gerhardt's Wintrich's Biermer's 

phenomenon phenomenon phenomenon 




Fig. 64. — Illustrating Gerhardt's and Biermer's phenomena and interrupted 
Wintrich's phenomenon. (Musser.) 

In hydropneumothorax we often observe Biermer's phenomenon, 
which is produced in the same manner as Gerhardt's in pulmonary 
cavities (see Figs. 63 and 64). 



CAVITIES 361 

Cracked-pot resonance, first described by Laennec, is occasionally 
obtained over cavities. Some precautions are necessary in order to 
elicit this sign. The patient should keep his mouth wide open, the 
pleximeter finger placed over the second or third intercostal space 
anteriorly, and with the percussion finger a strong blow is delivered 
without rebound, at the end of expiration. It is apparently a stenotic 
murmur at the opening of the cavity into a bronchus when the air is 
suddenly expelled through a narrow, slit-like opening. It may, how- 
ever, be met with in many other conditions, as in a crying child, and 
in adults with relaxed lungs, also in emaciated persons with resilient 
chest walls, and in cases of small emphysematous islands surrounded 
by consolidated lung tissue which are not uncommon in chronic 
phthisis. Of the many cavities that I have seen, cracked-pot reso- 
nance was present in but a small proportion. When obtained in con- 
nection with some of the other signs, it is of significance. 

Cavernous and Amphoric Breathing. — Auscultation may be altogether 
negative over deeply lying vomicae, or such as are completely closed 
by a plug in the communicating bronchus. Cavernous breathing is 
often heard; it resembles the sound produced while blowing into an 
inclosed hollow space. It is caused by the overtones developed in the 
cavity by reflection from the walls. Over cavities having smooth 
walls communicating with a bronchus we often hear amphoric breath- 
ing — a murmur with high overtones lacking deep basal tones, resem- 
bling the sound produced by blowing across the opening of a narrow- 
mouthed vase. Cavernous and amphoric breathing have a certain 
diagnostic significance. They indicate pulmonary excavation, bronchi- 
ectasis, or pneumothorax. Formerly it was thought that pneumo- 
thorax shows amphoric breathing only when it is freely communicating 
with a bronchus. But now we often find it over artificial pneumo- 
thorax, and it is then due to reverberation of the bronchial sounds 
from the smooth pleura. Over many excavations only loud and harsh 
bronchial breathing is audible. 

Over areas with amphoric breathing we usually elicit a dull note on 
percussion and, at times, cracked-pot resonance, while over areas 
with cavernous breathing we often get tympanitic resonance, though 
not always, as was already indicated. Amphoric resonance is an 
indication that the excavation is at least five centimeters in diameter, 
that its walls are smooth, round, and rigid, due to surrounding infil- 
tration or fibrosis; that in all probability it communicates with a 
bronchus of not very wide caliber; and that it is not active — a fibrous 
capsule prevents the absorption of toxic matter from the cavity, and 
also the extension of the lesion, and the small amount of secretion is 
soon eliminated by expectoration. It is for these reasons that cavities 
with amphoric breathing are usually not accompanied by any adven- 
titious sounds, excepting at times by a metallic tinkle, and this is 
very rare; while cavernous breathing is almost always accompanied 
by large or medium sized consonating rales or gurgles. In the latter 



362 CHRONIC PHTHISIS— ADVANCED STAGE 

case the cavity is active, probably growing and not surrounded by a 
fibrous shell. The prognostic significance is clear. The intensity of 
the amphoric phenomena depends on the stiffness of the wall which, 
in its turn, depends on a strong fibrous capsule or an infiltration and 
caseation of the surrounding lung. tissue. In the former case it will 
not enlarge and may even shrink, while in the latter case the excava- 
tion may extend and usually does. 

Metamorphosed Breathing. — Over the sites of cavities, mainly over 
the upper lobes, we sometimes hear the inspiratory murmur begin as 
a harsh or bronchial murmur, but during its course suddenly softens 
and changes in tone, finally ending with an amphoric sound. At times, 
both inspiration and expiration are thus affected. Laennec spoke 
of it long ago as a soufle wile, beginning as vesicular and ending as 
bronchial or amphoric. It seems that it is due to the breathing of a 
cavity. The air enters into a relaxed excavation and the murmur is 
modified while its walls are being distended or inflated. It is one of 
the best signs of an excavation, but it is only rarely met with. 

Adventitious Sounds Heard over Cavities. — Over excavations, large 
moist, bubbling, consonating rales — called in text-books metallic or 
cavernous rales — are often heard. They are caused by the air stream 
passing through the collection of fluid in the excavation. The size, 
pitch, timber, and duration of these rales depend on the size of the 
vomicse in which they originate, as well as the condition of its walls — 
whether they are smooth or ragged, rigid or relaxed, etc. On the 
other hand, over old cavities there may be audible amphoric breathing 
of an exquisite type, metallic breathing without any rales at all, 
because the fibrous walls do not secrete any more. These are cases 
that are doing well for years in spite of extensive excavations. 

In many cases the number of rales in excavations and their inten- 
sity are so great that they obscure all the breath sounds. 

The metallic tinkle is only rarely heard over pulmonary cavities. 

Pectoriloquy is met with over pulmonary cavities, but it is not 
pathognomonic of this condition. In many cases we hear the voice 
as if it is directly spoken into the ear with abnormal clearness. It 
merely indicates that the conditions for conduction are unusually 
good, which may be true of excavations, but are also met with in 
pneumothorax, and even in consolidated lung tissue through which a 
bronchus passes. 

The same is true of whispered pectoriloquy. But the transmission 
of the whispered voice with a metallic or amphoric echo, which Kuthy 
calls a amphorophony," is a sure indication of a smooth-walled cavity 
filled with air, either pulmonary or pleural, i. e., a tuberculous excava- 
tion or a pneumothorax. The differential diagnosis between these two 
conditions can, at times, be made out by the x-rays, and I have met 
with cases in which skiagraphy was not decisive. Some cavities can 
be made out by auscultation with much less trouble and greater relia- 
bility than with other diagnostic methods. Amphorophony is, however, 



CAVITIES 363 

only audible over old and larger cavities which are stationary, while 
over acutely progressive and extending vomicae it is only rarely heard. 
In many cases of localized pneumothorax I have found distinct whis- 
pered pectoriloquy in the axilla, which is exceedingly rare in cavity. 
This is a sign of great value in attempts at differentiation between these 
two conditions. 

Basal Cavities. — The vast majority of tuberculous cavities are formed 
in the upper lobes of the lungs, except in the terminal stages, when 
the resistance is very low, excavations then forming in the lower 
lobes of the lungs. 

They are very difficult of diagnosis. We may find signs of excava- 
tions at the base which are really "phantom caverns," as William 
Ewart 1 called them. The amphoric sounds of an excavation in the 
upper lobe are transmitted to the base by some transient or permanent 
consolidation. Echo may also be responsible for cavernous sounds 
at the base when the original excavation is situated in the opposite 
side of the chest and not in immediate contact with the spinal column. 

Basal cavities are to be differentiated from bronchiectasis and from 
syphilis of the lungs. In bronchiectasis the sputum- is mucopurulent, 
separates into three layers on standing, is occasionally putrid, brought 
up periodically in large quantities, and contains no tubercle bacilli. 
But all these may be encountered with phthisical cavities. The writer 
has been guided by the state of nutrition of the patient. If, in spite 
of the abundant and extensive bronchitis manifesting itself by profuse 
expectoration and numerous large, consonating rales and gurgles, 
the patient holds his own, the chances in favor of bronchiectasis are 
immense. Tuberculosis showing such activity is accompanied by 
pronounced emaciation, fever, nightsweats, and tubercle bacilli are 
not lacking. Syphilis of the lung with basal cavities is differentiated 
from tuberculosis by the presence of other stigmata of specific disease, 
the Wassermann reaction, and the continued absence of tubercle bacilli 
from the sputum. Finally, the diagnosis is at times only cleared up 
by the therapeutic test — antisyphilitic treatment acts promptly in 
most cases. 

It is important to mention that the prognosis is more unfavorable 
in basal cavities than in those located in the upper lobes, undoubtedly 
because they do not empty themselves with ease. Considering a 
pulmonary cavity as an abscess, we understand that when it does not 
drain the result must be disastrous ; the abundant secretions fill it up, 
and cough is not very effective in removing them. In the terminal 
stages of phthisis with lesions in the upper lobe, excavations sometimes 
form at the base, as we find them at necropsy, and kill the patient 
who may have been getting along very well before their occurrence. 
In fact, if in the course of chronic phthisis signs of excavation appear 
in the lower half of the chest, the prognosis is very gloomy. 

1 Goulstonian Lectures, British Med. Jour., 1882. 



364 CHRONIC PHTHISIS— ADVANCED STAGE 

Visceral Displacements. — The displacements of the mediastinal 
organs have already been referred to (p. 355). The heart is in most 
cases of advanced phthisis displaced toward the affected side of the 
chest, and in right-sided lesions we at times meet with complete dex- 
trocardia. But in many cases there are also to be noted displacements 
of the trachea and larynx, first described by E. Ruedinger. 1 More 
recently Gerald B. Webb, A. M. Forster, and B. G. Gilbert 2 described 
in detail the tracheal position in phthisis and suggested an easy method 
of detecting it: By placing the hand behind the neck while the thumb 
anteriorly reaches out to the trachea and rolls it, we can in most cases 
determine its position. It appears that in most cases of early phthisis 
the trachea is displaced toward the affected side. Webb found in 100 
cases of pulmonary tuberculosis of all s ages the recognition of the 
side especially affected proved correct in 69, doubtful in 19, and 
incorrect in 12 cases. It is due to pleural adhesions, together with 
fibrosis in the lung or pulmonary retraction pulling the trachea along. 

This deviated trachea is occasionally a source of error in diagnosis. 
When it is displaced to the margin of the sternum, we hear loud tracheal 
or even " cavernous" breath sounds both anteriorly and posteriorly, 
and thus diagnose a cavity which does not exist. Especially is this 
error of great moment when the trachea is displaced to the opposite 
unaffected side after the induction of a pneumothorax, and we may 
think that there is a cavity in the untreated lung. But a little care 
will usually clear up the case, especially when the possibility of dis- 
placement of the trachea is borne in mind. Webb says that movement 
of the trachea to the side of the healthier lung following the application 
of pneumothorax foretells a successful application of this procedure. 
In my experience this is not invariably the case. 

In many cases there is also upward displacement of the stomach 
and liver after pulmonary retraction. 

Duration of the Disease. — The duration of chronic phthisis is vari- 
able. Some patients get well, or succumb, within one year, while in 
most the sluggish course continues intermittently for many years, 
during which period the patients consider themselves cured, and 
suffer from "relapses" several times. They constitute the bulk of 
the class of patients who are admitted to sanatoriums and hospitals 
for consumptives several times. The reason is clear when we bear in 
mind the oscillating course of the disease — during acute or subacute 
exacerbations they seek relief in an institution, while during remis- 
sions, when the process is quiescent, they believe that they have been 
cured, or the disease has been arrested. 

Basing their estimates on heterogeneous material, different authors 
have estimated the average life of the consumptive as at from one to 
ten years. Leudet 3 found that of hospital patients 90.7 per cent, die 

1 Beitr. z. Klin. d. Tuberkulose, 1910, xvii, 151. 

2 Jour. Am. Med. Assn., 1915, lxv, 1017. 

3 Quoted from Kuthy and Wolff-Eisner, Prognosenstellung d. Tuberkulose, Berlin, 
1914, p. 56. 



MODES OF DEATH IN CHRONIC PHTHISIS 365 

within five years of the onset of the first symptoms; 9.3 per cent, 
during the sixth to the nineteenth year. He also found that among 
the more prosperous patients only 77.2 per cent, die within the first 
five years, and 22.8 per cent, between the sixth and the nineteenth 
years. Brown and Pope, 1 studying statistically the outlook of patients 
discharged from the Adirondack Cottage Sanitarium, found that of 
those discharged "apparently cured" at the end of five years, 94 per 
cent, of the expected were alive; at the end of ten years, 86 per cent. 
In those "arrested" the proportions for the corresponding years were 
63, 49, and 46 per cent.; and for those "active," 25, 15, and 10 per 
cent. It is thus clear that "an arrested" or even an "active" case is 
not necessarily doomed. There are always good chances to live for 
long years. 

The striking disparity in these two sets of statistics is due to the 
difference in the material. Leudet studied only fatal hospital cases, 
without including any of those who survived twenty years, while 
Brown and Pope studied cases discharged from a good sanatorium in 
which moderately well-to-do patients predominate, and among whom 
a fairly large proportion were affected with the abortive type of the 
disease. 

Attempts at estimating the average duration of life of the consump- 
tive have also met with failure because it is difficult to obtain com- 
parable material. When only acute, progressive cases are considered, 
the average is a low figure, one year or even less; when abortive 
cases are considered — and they are mostly those which have been 
diagnosed exceedingly early in the disease — the average is very high. 
It is for this reason that the estimates of "averages" vary from one 
to ten years, according to different authors. 

But for the individual patient, with whom the physician deals, 
averages do not count for much. He must be judged by the clinical 
manifestations. It may be stated that those who have long periods 
of quiescence live long; many practically their natural lives. They 
may be "cured" several times when they suffer from acute or subacute 
exacerbations, but they recuperate every time and live on, often 
with quite some efficiency. On the other hand, in the case of those in 
whom acute or subacute exacerbations are frequent, and each is of 
long duration, a fatal issue is inevitable sooner or later. 

Modes of Death. — Death supervening during an acute exacerba- 
tion, when the process in the lungs is extending, or the toxemia is 
severe, or the resistance is low, may be rapid, like from pneumonia 
or septicemia. The patient may have done quite well, but is suddenly 
stricken with high fever and prostration, and he succumbs to dyspnea, 
cardiac failure, etc. Usually the process is slower; the high continuous 
or remittent fever, the profuse nightsweats, anorexia, dysphagia due 
to laryngeal ulceration, extreme emaciation, etc., keep on for weeks 

1 Am. Med., 1904, viii, 879; Ztschr. f. Tuberkulose, 1908, xii, 205. 



366 CHRONIC PHTHISIS—ADVANCED STAGE 

or months; the patient is gradually but surely consumed by the dis- 
ease. In some, the last few weeks resemble in their symptomatology 
the typhoid state with marked prostration, muttering delirium, etc. 

In others, the cachexia progresses despite the fact that the fever is 
low, hardly ever exceeding 101° F., and the patients finally die from 
asthenia, like those suffering from malignant disease. Excepting the 
cough, diarrhea, and weakness they do not suffer much and, because 
the sensorium is well retained to the end, the euphoria may be exquisite. 
Others consider themselves quite well despite the extreme emaciation 
and attempt to walk around, against the advice of their physician, and 
among them death due to syncope may occur. Some of these unfor- 
tunates are occasionally found dead in bed in the morning. But in such 
cases it was usually not syncope, but a heavy dose of some opiate 
which abolished the reflexes, prevented cough and expectoration, and 
they were drowned by their own secretions. Other causes of sudden 
death during the night are spontaneous pneumothorax, copious 
hemorrhage, etc., killing before aid can be summoned. 

Complications of the disease are often responsible for a fatal issue. 
Among the most important are pulmonary hemorrhage and pneumo- 
thorax. While 98 per cent, of patients who suffer from more or less 
bleeding survive the accident, 2 per cent, succumb to it. The patient 
may feel comparatively well, and in fact consider himself on the way 
of recovery, or even cured, when suddenly brisk and profuse hemor- 
rhage occurs and kills him. Emaciated patients may die as a result of 
suffocation with their own blood, being powerless to expel it from the 
chest. 

Pneumothorax is the cause of death in about one of 150 fatal cases 
of phthisis. This may kill the patient within one or two days, the 
cause of death being asphyxia, or within a few weeks or months 
through complicating pyothorax. 

Complicating laryngeal tuberculosis is responsible for the death of 
many patients through dysphagia, dyspnea, edema of the glottis, etc. 

Between 5 and 10 per cent, of deaths from phthisis are preceded by 
cerebral symptoms. Most of these are due to tuberculous meningitis, 
but some are also caused by uremia, as was already stated. 

Premonitory Signs of Death. — In chronic phthisis with tendencies 
to a fatal issue, it is often very difficult to prognosticate the time 
when the end will come. Indeed, the more extensive the experience 
of a physician with this disease, the more guarded he becomes in 
foretelling the day of death. Such statements as "he cannot survive 
three days," or "he will surely die within a week," etc., should be 
avoided. Some patients keep on living for weeks or months under 
conditions which are puzzling, to say the least. 

There are symptoms and signs which may, however, be considered 
precursors of death in phthisis. Of these we may mention: Dysphagia, 
due to laryngeal ulceration, when not quickly relieved by treatment, 
is a sure indication that the patient will not survive very long. The 



PREMONITORY SIGNS OF DEATH 367 

same is true of profuse diarrhea which cannot be controlled by treat- 
ment. The emaciation is extreme, and the end comes rapidly. But 
I have seen cases with profuse diarrhea lasting for months, in spite 
of the fact that they hardly assimilated any nourishment. The reason 
is clear when we consider that the emaciated victim of phthisis lies 
quietly, hardly moving a limb, or expending any energy, so that the 
least fuel is sufficient to keep the spark of life aglow. 

Edema of the extremities very often appears shortly before death. 
It is usually due to cardiac weakness or nephritis, thrombosis or 
thrombophlebitis. It may be unilateral, but usually both lower 
extremities are affected. The swelling may be enormous in extreme 
cases, while in most it is but moderate and tender on pressure. When 
this edema of the lower extremities is combined with cyanosis and 
dyspnea, a fatal issue may be expected within a month. Thrombosis 
of the femoral, jugular, subclavian, or other veins is one of the surest 
premonitory signs of death. 

Aphthous stomatitis commonly portends death. In some cases 
treatment may improve the condition in the mouth, but within a few 
weeks the powers of life wane and death supervenes. Another sign 
which justifies information to relatives that the end is near is a red, 
spongy condition of the free edge of the gums. 



CHAPTER XXI. 
ACUTE PHTHISIS. 

Just as in other infectious diseases, there are observed in tuber- 
culosis acute, malignant, or fulminating forms which run a shorter 
and almost invariably fatal course. They are relatively rare, as 
malignant scarlet, measles, typhoid, etc., are rare. Every practitioner 
meets with these acute cases and the laity is well aware of their 
existence. When tuberculosis makes its appearance in a member of 
a family anxious inquiries are made to ascertain whether it is not 
"hasty," or "galloping consumption," the names under which acute 
tuberculosis is commonly known. Pathologically, the lesion is prac- 
tically the same as that of the chronic forms of the disease, considering 
that there are no two cases of phthisis in which the anatomical changes 
are exactly alike, but clinically it manifests itself by a more rapid 
course, the patient lasting as many months with the acute form as 
years with the chronic forms. Acute tuberculosis may be said to be 
active chronic phthisis without the remissions and ameliorations char- 
acteristic of the course of the latter affection. 

It is unnecessary to enter into hair-splitting distinctions of the 
pathological and clinical types of acute phthisis described by some 
authors, notably the French. In practice we meet mainly with two 
types of the disease: The lobar pneumonic type — acute pneumonic 
phthisis, and the lobular, or bronchopneumonic type. In the former 
the patients are usually adults, while the latter attacks mainly infants 
and very young children, and adults only at the terminal stages of 
chronic phthisis. 

Between the two extremes — chronic and acute phthisis — there 
are many gradations; some are very acute, the patient being carried 
off within one or two weeks; some are subacute, lasting for two to 
four months, others even a year, but without any remissions in the 
progress. Then there are acute exacerbations during the course of 
chronic phthisis which are anatomically and clinically of the same 
character as the acute or subacute forms and often bring hitherto 
hopeful cases to a speedy termination. I have also met with cases 
which began acutely and kept up in that manner for several weeks, 
but suddenly, or by degrees, took a turn for the better, and the patient 
passed through the course of chronic phthisis subsequently. 

Etiology. — -The factors operative in causing an acute and malignant 
evolution of phthisis in some cases, while in the vast majority it is 
chronic, slow, and more or less benign, are not clear. From a careful 
study of the cases met in practice it appears that the general condition 



SYMPTOMATOLOGY OF ACUTE PHTHISIS 369 

of the patient before the onset of the disease has no influence in this 
direction. In fact, it appears, as was already stated (see p. 125), 
that phthisis in those who suffered from scrofula during childhood, 
or who are descended from tuberculous stock, is more likely to run a 
slow, sluggish course. On the other hand, we very often meet with 
acute phthisis in persons who have no hereditary taint, who have 
been in excellent condition, and only rarely in the weakly and decrepit, 
excepting tuberculous bronchopneumonia in infants. 

The problem whether these acute cases are invariably due to more 
virulent strains of tubercle bacilli has not been solved, though there 
appears to be no evidence in favor of such a view. Some authors 
have held that acute phthisis is caused when a tuberculous cavity or a 
caseating gland breaks through into the lung, disseminating the secre- 
tions containing bacilli, but this is negatived by the fact that we meet 
numerous patients who never coughed before the onset of the acute 
disease. 

It appears that individuals who have never before been in tubercle- 
laden surroundings are more likely to develop acute phthisis when 
infected primarily after they have passed the age of childhood, as we 
have already shown (see p. 127). The same "virgin soil" is presented 
by infants: when they are infected with tuberculosis they very often 
suffer from the acute forms of the disease, and so do adults hailing 
from rural districts where they have not met with tuberculosis, so 
that if infection takes place it is primary. The explanation of these 
phenomena has been discussed in a previous chapter. 

Acute Pneumonic Phthisis. — The anatomical changes are those of 
pulmonary tuberculosis but the process of caseation and liquefaction 
gains the upper hand, not being limited by the conservative process of 
fibrosis which is a strong feature in chronic phthisis; little or no con- 
nective tissue is formed to localize the lesion. Usually the greater 
part of a lobe, or a whole lobe, is affected. The parenchyma is trans- 
formed into a solid, caseous, or gelatinous mass within which there can 
often be found a focus representing an old lesion. The destruction of 
lung tissue goes on at a rapid pace, and within a short time more or 
less extensive excavations may be formed. But these excavations 
are not surrounded by a connective-tissue wall; all around them is 
caseated lung tissue. In many cases, however, death supervenes 
before softening has had time to set in and sequestrate the affected 
part of the lung. ^Ye may find scattered tubercles or caseous nodules 
all over the affected lung and also in the other, as well as on the visceral 
pleura, but pleural adhesions are extremely rare. 

Symptomatology. — The disease is mostly seen in adults between 
twenty and forty years of age. The onset and symptoms during the 
first few days are akin to those of lobar pneumonia. In fact, most of 
the cases of chronic phthisis which are said to have begun as lobar 
pneumonia are cases of acute pneumonic phthisis which were not 
recognized as such at the onset of the acute stage. 
24 



370 ACUTE PHTHISIS 

As given by the patients, the onset is nearly always acute. After 
some alleged exposure there was a chill, fever, pain in the chest, cough, 
etc. But a careful inquiry elicits that while the acute symptoms have 
come on suddenly, the patient has for weeks, perhaps for months, 
felt out of sorts; was unable to perform his usual work without fatigue; 
in fact, he has coughed, expectorated and may have had some night- 
sweats. But all these symptoms were not sufficiently pronounced to 
cause alarm; even if he has consulted his physician he may have been 
told that his troubles were trifling. This long prodromal stage is of 
great diagnostic importance, and wiU often aid while attempting to differ- 
entiate acute pneumonic phthisis f rem lobar pneumonia. 

With the acute symptoms the patient is laid up in bed. The dyspnea 
is marked from the beginning, and may be paroxysmal. The pain in 
the side is mild and only rarely as acute as in pneumonia or pleurisy, 
or may be altogether lacking. Cough is nearly always annoying; 
it may be severe, incessant and exhausting. At first dry, it slowly 
becomes productive and the sputum is at times rusty and viscid, 
adhering to the sides of the vessel like in lobar pneumonia. But in 
most cases it is mucopurulent, frothy and easily brought up. In some 
cases it is sanguineous, at times repeated, small, true hemoptyses 
take place, and the disease may begin with a profuse pulmonary 
hemorrhage. When softening and excavation take place, which occur 
quite soon, the sputum is of the same character as that of chronic 
phthisis, excepting that it is more often green in color. In the begin- 
ning repeated microscopic examinations do not reveal any tubercle 
bacilli, and, because pneumococci are quite frequent, the diagnosis is 
very difficult. Only after the disease has lasted for a couple of weeks, 
and very often much later, and we may be thinking that we are dealing 
with an unresolved pneumonia, tubercle bacilli are discovered in the 
sputum. 

Weakness, anorexia, emaciation and fever are very strong clinical 
features in the evolution of the disease. The weakness may be so 
severe that very early in the course of the disease the patient is unable 
to sit up in bed, or to breathe for the purpose of auscultation. When 
examined he falls back in bed exhausted, pale and cyanosed. This 
asthenia is not seen in the average case of lobar pneumonia. With the 
anorexia, which may be pronounced from the very beginning, emacia- 
tion goes hand in hand. Even in the cases in which the appetite 
is somewhat retained, the emaciation is very early and pronounced, 
and out of proportion to the fever and anorexia. It usually proceeds 
rapidly and often frightfully, so that within a few weeks a normally 
built man is reduced to a skeleton. Wasting is particularly quick in 
the muscles of the chest. 

In the beginning the fever is of a continuous type, like in lobar 
pneumonia, though some authors have described pneumonic phthisis 
without high fever, which I have never met in my practice. But this 
is rare during the first few weeks when the temperature curve ex- 



DIFFERENTIAL DIAGNOSIS OF ACUTE PHTHISIS 371 

quisitely simulates that of lobar pneumonia, but during the second 
week, when we expect defervescence, we are disappointed. Instead 
of this, the fever becomes intermittent, or hectic, with morning 
remissions to normal or even below, and afternoon rises to 103° or 
104° F., and accompanied by copious nightsweats. The pulse is rapid, 
small and feeble, and the blood-pressure low. The full, vigorous pulse 
of lobar pneumonia is never found. 

Physical Signs. — Physical exploration of the chest often shows the 
signs of typical lobar pneumonia. There is impaired resonance or 
dulness over the upper part of one side of the chest above the third 
rib. But instead of the harsh tubular breathing which is character- 
istic of pneumonia, we usually perceive diminished and, in some cases, 
complete absence of breath sounds, which are replaced by moist, sub- 
crepitant rales. The crepitation of pneumonia is only rarely audible. 
With the advance of the lesion the dulness becomes more pronounced 
and the respiratory murmur may be altogether abolished, or bronchial 
breathing may become audible coupled with small and medium-sized 
moist rales. In acutely progressive cases signs of excavation may be 
found within four weeks, but this is rare. 

Course.— In most cases the acute symptoms persist for two or three 
months, the lesion softens, extensive excavations may form and the 
patient finally succumbs to asthenia. In some the process is of shorter 
duration; I have seen cases in which death occurred in less than 
three weeks. On rare occasions the disease is acute for four to six 
weeks, when an improvement in the general condition takes place and, 
with more or less extensive excavation in a lung, the patient becomes 
a chronic consumptive and the disease may even be arrested in time, 
which is, however, very rare. In some the toxemia is very severe and 
the patient succumbs within two or three weeks, even before softening 
has taken place. The prognosis under the circumstances is very grave, 
the average duration of the fatal cases, and they are in the vast major- 
ity, is about six weeks, dying from toxemia and exhaustion. I have 
seen several cases in which the end came through a brisk pulmonary 
hemorrhage. 

Differential Diagnosis. — It is often very difficult to differentiate 
acute pneumonic phthisis from lobar pneumonia, especially during 
the first two weeks of the ailment. Mistakes may be avoided by 
carefully inquiring for premonitory symptoms of tuberculosis pre- 
ceding the acute onset, such as anorexia, emaciation, weakness, mild 
cough, nightsweats, etc., which are frequent in acute phthisis, while 
in lobar pneumonia the patient is stricken suddenly when he feels in 
the best of health. In fact, in atypical pneumonia, acute tuberculosis 
is always to be thought of. The same may be said about apical pneu- 
monia. The absence of pain in the side, the late arrival of true bron- 
chial breathing, the hemoptysis, etc., may all lead to a diagnosis, or 
at least a suspicion of acute phthisis. An irregular temperature curve, 
mild dyspnea, severe pallor, low leukocyte count, absence of pneumo- 



372 ACUTE PHTHISIS 

cocci from the sputum, and a strong diazo-reaction may also be con- 
sidered. Of great importance in favor of acute phthisis is yellow or 
green sputum. Tubercle bacilli are conclusive evidence, but they are 
only rarely found before the end of a month. During the first week 
the emaciation is negligible in pneumonia, irrespective of the acuteness 
of the symptoms, while in phthisis it is immediately pronounced; 
nightsweats, weakness and edema of the lower limbs are frequent. 
The crisis, which is sure to come before the fourteenth day in the vast 
majority of cases of pneumonia, will clear up doubtful cases. 

Especially difficult is the diagnosis of pneumonic phthisis in aged 
persons, in whom it may occur without much fever and other general 
symptoms, and only positive sputum can decide. 

TUBERCULOUS BRONCHOPNEUMONIA. GALLOPING 
CONSUMPTION. 

Etiology. — The anatomical changes in tuberculous bronchopneu- 
monia are those of pulmonary tuberculosis, excepting that the lesion 
is not localized in one apex, or one lobe, but disseminated all over one 
or both lungs in which there are distributed caseous nodules which 
vary in size from that of a pin-point to that of a walnut. Some authors 
have been inclined to attribute the wide dissemination of the lesion, 
as well as the acute course of this form of tuberculosis, to mixed infec- 
tion with tubercle bacilli and pyogenic microorganisms. This, they 
believe, is confirmed by the fact that it very often follows infections 
such as measles, whooping-cough, influenza, typhoid, etc., showing 
that the patient had harbored a tuberculous process before, but with 
the addition of a new infective agent his vitality was reduced and the 
tuberculous process allowed to spread all over the lungs. But against 
this view may be brought forward the numerous cases in which mixed 
infection can be positively excluded. 

In most cases it appears to be the result of the wide dissemination 
of the contents of a tuberculous cavity in the lungs, or the perforation 
of a tuberculous lymph node, the contents of which are aspirated, 
carried all over the bronchial tree and take root in various parts of the 
lungs. In infants, among whom this form of the disease is very common, 
it may be due to a primary massive infection with tubercle bacilli; 
the body possessing no immunity through previous infection, the 
result is the same as when a guinea-pig is infected. In adults, we also 
meet it in women after childbirth, in tuberculosis with diabetes and 
alcoholism, etc., when the resisting powers are at low ebb, and immu- 
nity acquired by the existing lesion is lacking. 

Symptoms. — Tuberculous bronchopneumonia in adults is usually 
found in patients who have been tuberculous for some time. In 
those in whom it appears to be of sudden onset, careful inquiry elicits 
the information that the patient has been ailing for some time with 
symptoms highly suggestive of tuberculosis. In fact, 'it is often a 



TUBERCULOUS BRONCHOPNEUMONIA 373 

complication of chronic phthisis: A patient who has been doing 
fairly well suddenly develops acute symptoms without any special 
cause; more often after a surgical operation in which a general anes- 
thetic was employed. Tuberculous women are frequently the victims 
soon after childbirth. 

The clinical picture is that of an acute infectious disease with pro- 
nounced toxemia. The onset is sudden, often with a chill, fever, 
backache, cough, expectoration, etc. The fever is usually high — 
103° to 104° F. is not uncommon — and in children it may be even 
higher. The temperature curve is not characteristic; in fact, it may 
be stated that its peculiarity is its irregularity. In many cases it 
is continuous with slight remissions, but in others it is intermittent, 
with chills before each rise. During the terminal stages it is usually 
hectic. The sweats are profuse and exhausting, the pulse feeble, 
small and rapid, 120 to 150 is not rare; the dyspnea is marked — 40 
to 60 per minute are very often counted and cyanosis is a frequent 
feature. Graves spoke of "acute tubercular asphyxia." 

The intensity of the cough is variable: In some patients it is severe, 
painful, paroxysmal, and may provoke vomiting. While occasionally 
the cough is mild, in most cases it is more severe than in chronic 
phthisis. At times expectoration is absent or scanty, but usually it 
is more or less abundant, often purulent, and, with the advance of the 
disease, nummular; yellowish-green balls are brought up. Tubercle 
bacilli are found in most cases. 

Hemoptysis is frequent in adults and may be quite copious; many 
cases begin with pulmonary hemorrhage. 

The appetite is rarely fairly well retained, but in most cases this, 
as well as the digestive functions, is impaired; many have to be coaxed 
to take some nourishment. Emaciation proceeds at a rapid pace. 
Because of the flushed face it is at times not appreciated at first sight, 
but when the bedclothes are removed, the marked wasting of the 
subcutaneous tissues and muscles of the chest and extremities presents 
a frightful picture, especially when it is considered that it may have 
been consummated within a few weeks. 

Physical Signs. — The physical signs vary according to the nature 
of the anatomical changes in the lungs. In the beginning they may 
be obscure and misleading. In most cases the note elicited on per- 
cussion is hyperresonant all over the two sides of the thorax; localized 
dulness is found only later when some of the disseminated tubercles 
have become confluent. Auscultation shows either feeble breathing 
or harsh bronchovesicular breath sounds all over the chest, coupled 
with sibilant and sonorous rales. With the advance of the disease, 
which may be within but one or two weeks, we find localized areas, 
not necessarily in the apex, especially in children, of consolidation 
with bronchial breathing and moist subcrepitant rales which soon 
change their character when excavation takes place and the usual 
signs of a cavity can be made out. In many cases, notably in children, 



374 ACUTE PHTHISIS 

signs of diffuse bronchitis are found all over the chest, while in others 
the toxemia is so severe that the patient succumbs before definite 
changes in the resonance and breath sounds have developed. 

Complications. — Among these may be mentioned pulmonary 
hemorrhage, which may be fatal; intestinal tuberculosis, tuberculous 
meningitis, and general miliary tuberculosis. 

Diagnosis. — The diagnosis is very difficult in the initial stages, 
particularly in children, among whom it must be differentiated from 
postgrippal bronchopneumonia, and sputum is not available for 
microscopic examination. In adults it is usually more easily diag- 
nosticated. We find in patients who have been tuberculous for some 
time that after a hemorrhage, surgical anesthesia, pregnancy, etc., 
the symptoms suddenly take a sharp turn and galloping consump- 
tion follows. It is always to be borne in mind that when in a person 
who never before had emphysema, and who has no barrel-shaped chest, 
symptoms and signs of emphysema suddenly make their appearance 
accompanied by acute constitutional symptoms such as fever, cough, 
nightsweats, etc., acute phthisis is to be thought of. The sputum will soon 
clear up the diagnosis. With the advance of the disease the physical 
signs are easily made out. 

Prognosis. — The prognosis is very grave Some acute cases run 
a rapid course, terminating fatally within four or six weeks, and in 
children in a shorter time. Many cases linger for three or four months 
and die of asthenia. I have met some cases in which the disease came 
to a halt and assumed the character of chronic phthisis. 



CHAPTER XXII. 
FIBROID PHTHISIS. 

Fibrous Hyperplasia in Phthisis. — Discussing the morbid anatomy 
of phthisis, we showed that while the tuberculous process is mainly 
one of destruction — infiltration, caseation and softening — there are 
reparative forces at work in almost every case, manifesting themselves 
principally in the formation of connective tissue which either heals 
the lesion through cicatrization, or at least limits its progress. In fact, 
it may be said that without the formation of connective tissue, every 
case of phthisis would be acute. The balance between the destructive 
and reparative processes in phthisis depends consequently on the 
amount of fibrosis within and about the lesion — the more intense the 
formation of fibrous tissue the slower the progress of the disease, and, 
conversely, the less the fibrosis the more acute and progressive the 
disease. 

We must distinguish between fibrosis and formation of cicatrices. 
When a lesion cicatrizes, the activity of the tuberculous focus is 
extinguished, though without any restitutio ad integrum, as is seen in 
healed tuberculous lesions of the lungs and pleura. But in fibrosis 
the lesion is an active, inflammatory process, though it may be only 
slightly progressive, yet connective tissue is being continually produced. 
In other words, in fibroid phthisis the destructive process is smoulder- 
ing, though in abeyance, or entirely absent, and the proliferative pro- 
cess dominates. As Bard says, the lesions may be progressive and 
spreading, though they are not of a destructive character. 

It must also not be confused with fibroid degeneration of the pul- 
monary parenchyma which at times follows acute or chronic non- 
tuberculous inflammatory processes of the lungs, such as the so-called 
interstitial pneumonia, pulmonary induration or cirrhosis, etc. Fibroid 
phthisis is a specific proliferation of the lung tissue caused by tubercle 
bacilli. 

Clinically this form of tuberculosis is characterized by an exceedingly 
chronic course extending over many years, finally leading, in most 
cases, to the development of the symptoms and course of the common 
form of chronic phthisis. It differs from other forms of inflammatory 
fibrous degenerations of the lung in that it is caused by the tubercle 
bacilli, and that the characteristic tuberculous giant cells are found 
microscopically in the lesions of fibroid phthisis. 

Fibroid phthisis was mentioned by Bayle one hundred years ago 
and ever since by many others; Sir Andrew Clark 1 coined the term, 

1 Fibroid Diseases of the Lung, London, 1906. 



376 FIBROID PHTHISIS 

and made a thorough study of the pathology and symptomatology of 
the disease. C. J. B. and C. T. Williams, 1 hi their book on consump- 
tion, also give a complete description of this form of phthisis. Of 
the more recent writers who treat of this subject may be mentioned 
Bard, 2 Sokolowski, 3 and Piery. 4 While most of the authors do not 
agree on the various points which characterize fibroid phthisis, yet in 
the main they are in agreement on its differentiation from all other 
forms of pulmonary tuberculous disease. 

Etiology. — Fibroid phthisis is mainly encountered in persons between 
forty and sixty years of age and, contrary to the statements of many 
authors, it may occur in younger individuals. Apparently many cases 
are treated for chronic bronchitis, asthma, pulmonary emphysema, 
etc., and only after the process has lasted for many years is the char- 
acter of the affection recognized; an intercurrent hemorrhage or 
tubercle bacilli in the sputum reveals the true nature of the disease. 
I have met with many cases in persons under thirty years of age. 

It appears that syphilis is an important etiological factor; when 
both tuberculosis and syphilis are met with in the same individual, the 
process of the former is often of the fibroid type. Sergent 5 and several 
other French writers have indeed maintained that most fibroid cases 
are a manifestation of syphilis and tuberculosis. Several English 
authors hold the same view. Thus, J. Mitchell Bruce 6 says: "It 
should be noted that some cases of quiescent phthisis give a history 
of syphilis which may account for the disposition to fibrosis, and 
pro t'anto may be a favorable element prognostically." In my expe- 
rience this holds true for some cases but not for the majority. I have 
seen many cases of fibroid phthisis in which specific disease was posi- 
tively excluded, and at the Montefiore Home, where we have many 
of these cases, the Wassermann reaction is only rarely positive, and 
the other stigmata of syphilis are lacking in the majority of cases of 
fibroid phthisis. 

English authors, notably Clark, have observed that the gouty 
diathesis, which is antagonistic to tuberculosis, is responsible for the 
fibroid form of phthisis. This is not in agreement with my experience, 
because among the poor in Xew York City gout is rather rare, while 
fibroid phthisis is quite common. Xor have I found any etiological 
relations between fibroid phthisis and alcoholism, or social and eco- 
nomic conditions, etc. 

It appears to me that occupation is of greater etiological moment. 
Most of the cases I have seen were in persons Working indoors, inhal- 
ing animal and vegetable dust — garment-workers, furriers, rag-pickers, 



1 Pulmonary Consumption, London, 1887. 

2 Forms cliniques de la tuberculose pulmonaire, classification et description sommaire, 
Geneve, 1901. 

3 Klinik der Brustkrankheiten, Berlin, 1906, ii, 410. 

4 La Tuberculose pulmonaire, Paris, 1910. 

5 Presse medicale, 1908, xvi, 657. 6 Lancet, 1913, i, 591. 



FORMS OF FIBROID PHTHISIS 377 

etc. It seems also that chronic lead poisoning is a predisposing factor, 
because of its frequency among plumbers, printers and house painters. 
In former days it was frequently seen among chimney-sweepers, and 
today it is met with among those who inhale any irritative dust, as 
knife-grinders, coal-heavers, button-makers, etc. 

Pathology. — The pathology of fibroid phthisis has been thoroughly 
studied by Sir Andrew Clark, who described that the affected lung is 
usually decreased in size; sometimes its dimensions do not exceed the 
size of a closed fist. In local fibrosis only the affected part of the lung 
may be contracted while the rest fills up its place by compensatory 
emphysema. Cavities — pulmonary and bronchiectatic — are common, 
surrounded by dense, rigid walls. Cheesy nodules encapsulated by 
fibroid tissue are frequent, and during the final stages the caseating 
process gains the upper hand and breaks through the limiting and 
protective fibrous tissue spreading the destructive process. The 
walls of the alveoli are thickened and finally obliterated or filled in, 
the interlobar connective tissue, especially around the large vessels and 
bronchi, proliferates enormously and, replacing the parenchymatous 
tissue of the lung, produces a state of induration through which the 
dilated bronchi pass. 

In all cases of fibroid phthisis the pleura is thickened over the 
affected area, sometimes attaining a thickness of one-half to three- 
fourths of an inch. The pleural cavity is adherent and, in the pleural 
form, obliterated by tough fibrous tissue binding the two surfaces 
together, and from it other bands of connective tissue are sent forth 
into the lung which contract and drag along toward the affected side 
the mediastinum, the diaphragm, and with it the liver, etc. 

We are not clear why the tubercle bacilli produce caseation and 
liquefaction of tissue in most cases, while in others a proliferation of 
connective tissue is the dominant feature after infection. We know 
that in many cases of fibroid phthisis we have an additional etiological 
factor, the inhalation of mineral, animal, and vegetable dust. But 
on the other hand, the form which will be described as the pleural 
form of fibroid phthisis is not usually associated with the inhalation 
of irritating dust, but the causative factor seems to be bacterial, plus 
the predisposing factors which are operative in the other forms of 
chronic phthisis. 

We are in the dark about these problems. It has not been proven 
that in fibroid phthisis the tubercle bacilli are of some attenuated 
strain, or of the bovine type. In many cases of fibroid phthisis in which 
tubercle bacilli are not detected, Much's granules have been found, 
thus pointing to bacilli which have lost their acid-fast properties 
being the cause; but this also requires further study. 

Forms of Fibroid Phthisis. — The symptomatology of fibroid phthisis 
depends on the form of the disease. My experience is in agreement 
with that of Sokolowski, excepting that I meet with a pleural form in 
addition to his two forms — simple fibroid phthisis and fibroid phthisis 



378 FIBROID PHTHISIS 

with emphysema. The most common clinical form encountered by 
me is the emphysematous. 

The Emphysematous Form. — The patient has usually been a chronic 
cougher, expectorated for years and felt short-winded, especially on 
exertion, as climbing stairs. He- may have consulted physicians 
repeatedly and was informed that the trouble was not of serious import; 
that it was chronic bronchitis, pulmonary emphysema, etc. Inas- 
much as he has been able to pursue his occupation, he more or less 
disregarded the cough, expectoration, dyspnea, etc. During the 
winter and autumn these patients are usually subject to "colds," 
"grippe," etc., when the cough is aggravated and persists for several 
weeks with greater severity than usual. 

In some patients, especially those engaged in trades involving the 
inhalation of animal or vegetable dust, the signs of pulmonary emphy- 
sema, as well as attacks simulating essential asthma, are apt to come 
on suddenly in one who has never before suffered from any respiratory 
trouble. In fact, experience has taught me to look with grave sus- 
picion on each case of emphysema or asthma coming on suddenly in 
a person over thirty years of age. 

During the early stages of the disease, and this may last for many 
years, the patient, though coughing and suffering from mild dyspnea, 
pursues his vocation without interruption. Fever is lacking, excepting 
during an acute exacerbation or some intercurrent affection. The 
expectoration is scanty; in fact, the cough is usually dry, or some glairy 
mucus is brought up after a fit of coughing. A search for tubercle 
bacilli is usually fruitless. But the dyspnea is annoying and increases 
on slight exertion. 

The general appearance of the patient is that of a healthy person, 
the panniculus adiposis is well preserved, and in those who do not 
work at hard manual labor, and in women, we may meet with marked 
obesity. The "fat phthisis," of which we spoke above, is seen almost 
exclusively in fibroid patients. On the other hand, there are some 
patients who are more or less emaciated, but they are usually indi- 
viduals who have never been fat; but even they gain rapidly after the 
physician urges them to rest and feed up. I have met with some who 
have gained twenty or even more pounds in a couple of months and 
retained it for years. 

The vast majority of fibroid patients have clubbed fingers and curved 
nails. The most exquisite forms of drumstick fingers may be found 
among them, while they are not so common among those who suffer 
from common chronic phthisis. 

Many get along airly well for years without suspecting the real 
nature of their trouble, until they are suddenly seized by attacks of 
hemoptysis which may be slight, or quite profuse, but which usually 
frighten them out of their wits. In some, the hemoptysis is quite 
frequent and may at times be copious, while in most it is rare and 
consists only in one or two mouthfuls of blood or streaky sputum. 



COURSE OF FIBROID PHTHISIS 379 

It may appear suddenly while the patient has considered himself in 
excellent condition. It may recur at irregular intervals. Hemor- 
rhagic phthisis usually is fibroid phthisis, and most patients bear the 
bleeding very well indeed. I had one patient who was so used to 
hemoptysis that it no longer frightened him. We meet with some who 
never expectorated blood. 

Well-to-do patients without profuse hemoptysis get along for years 
without troubling themselves about the cause of their mild cough 
and dyspnea, unless they apply for life insurance, and after they are 
rejected for 'lung trouble" they promptly consult a physician. 

Physical Signs. — A physical exploration of the chest usually reveals 
an emphysematous, or barrel-shaped, chest in those who suffered for 
years, while in those who have only recently acquired the disease, 
the thorax may be of normal shape. Careful inspection shows some 
flattening of the supraclavicular, infraclavicular, and supraspinous 
fossse, more marked on one side of the chest, wasted muscles of the 
neck and shoulder, and shoulder droop on the same side, coupled with 
lagging and restricted motion. On percussion, defective resonance, 
or even dulness, is elicited on one side above the second or third rib 
anteriorly and posteriorly, while below, and all over the opposite side 
of the chest, the note is hyperresonant, or slightly tympanitic, and the 
inferior margin of the lung is one or two inches lower than normal 
and hardly mobile. Narrowing of Kronig's resonant area can easily 
be made out; in fact, it appears somewhat accentuated because the 
opposite unaffected apex is larger, owing to emphysema. Auscultation 
shows feeble breathing all over the chest, while over the site of the 
dulness the expiratory murmur is harsh and prolonged, at times show- 
ing a bronchial timbre. Dry crackles, or rales after cough, may be 
audible, in others sibilant or sonorous rales are heard all over one side 
of the chest. During one of the asthmatic attacks, which in some 
patients are quite frequent, so that they are treated for asthma, we 
hear wheezing, sibilant and sonoious rales all over the chest, exqui- 
sitely simulating bronchial asthma. 

Course of the Disease. — These patients get along quite well till 
they pass middle age. Most of them, if they are under medical care 
at all, are considered individuals who are troubled with chronic bron- 
chitis, pulmonary emphysema, asthma, etc. But sometimes between 
the age of forty and. sixty, though exceptionally I have seen it in 
younger individuals, the clinical picture changes. They begin to lose 
weight gradually but persistently, so that sooner or later they present 
the unmistakable appearance of the average consumptive in the 
advanced stages of the disease. The cough becomes more severe 
and productive of globular and nummular sputum containing tubercle 
bacilli and elastic tissue, etc. The cyanosis and the dyspnea become 
more and more marked, and finally orthopnea sets in with signs and 
symptoms of dilatation of the right heart which is almost constant at 
this stage, followed by edema of the lower extremities, hydrothorax, 



380 FIBROID PHTHISIS 

etc. Intestinal and laryngeal tuberculosis are quite common, and con- 
tribute to the misery of the patients who finally expire from asystole 
or inanition. 

The signs in the chest do not differ markedly from those met with 
in the usual case of far advanced phthisis — signs of cavitation at the 
apices, as well as of diffuse bronchitis are common. Skiagraphy, which 
in previous stages showed only signs of emphysema with some retrac- 
tion of one or both apices, now reveals more or less extensive cavities 
and peribronchial infiltration. Displacements of the mediastinum are 
more frequent than in common chronic phthisis. 

Diagnosis. — In the later stages of the disease the diagnosis is clear 
and it differs from that of chronic phthisis mainly because of the 
dyspnea, cyanosis, edema and clubbed fingers, which are not so com- 
mon, or less marked, in the latter condition. In the earlier stages, 
however, fibroid phthisis is difficult to differentiate from pulmonary 
emphysema, chronic bronchitis and, at times, from bronchial asthma. 
The persistently negative sputum is especially perplexing. Errors 
may, however, be reduced to a minimum by carefully examining the 
apices in each case of chronic bronchitis and pulmonary emphysema. 
Whenever the physical signs point to infiltration of an apex, fibroid 
phthisis is to be thought of. The symptoms and signs of asthma com- 
ing on suddenly in one who works in surroundings laden with animal, 
vegetable, or mineral dust, usually point to fibroid phthisis. 

Simple Fibrosis. — These are cases of fibroid phthisis in which the 
onset, course, and termination of the disease are practically the same 
as in the form just described, excepting that the symptoms of pul- 
monary emphysema are lacking. The onset is slow and insidious. 
The patient is troubled with an occasional morning cough, expecto- 
rates little or nothing, and the sputum contains no tubercle bacilli or 
elastic tissue. There is, however, slight dyspnea on exertion which is 
often overlooked. 

The general condition of the patient leaves little or nothing to be 
desired. He has no fever, no nightsweats, no anorexia, emaciation, 
etc. All he complains of, if at all, is that he is subjected to " colds," 
especially during the winter months; of breathlessness, and of hemop- 
tysis, which may be quite a feature in this form of phthisis when 
occurring often, or it is copious. But before, during, and immediately 
after the hemoptysis there is usually no fever, and convalescence, is 
rapid. In fact, many of the patients feel much relieved after the 
effects of a brisk pulmonary hemorrhage have passed away. These are 
the cases which some English authors have described as "arthritic" or 
"gouty" hemoptysis, because some of these patients, though not all, 
present some of the stigmata of the arthritic diathesis. 

Many of these patients present themselves to their physician, who 
makes a careless examination of the chest and, finding no sign of tuber- 
culous infiltration, assures them that the bleeding came from a ruptured 
bloodvessel in the throat, etc. Thus reassured, they return to work, 



DIAGNOSIS OF FIBROID PHTHISIS 381 

feeling quite well. However, in many there are signs of active phthisis 
in one of the apices: Impaired resonance, contraction of Kronig's 
resonant area, harsh bronchovesicular or distinctly bronchial breath 
sounds, more or less numerous rales, all localized, circumscribed and 
persistent above the second rib anteriorly and posteriorly over the 
supraspinous fossa in one side of the chest. The physician is often 
amazed to find the patient in such excellent condition for years despite 
the signs of a distinct and active pulmonary lesion, and is apt to 
attribute it to chronic apical catarrh. 

In other cases the onset is, however, not so insidious. A fairly 
healthy person is suddenly seized with a pulmonary hemorrhage which 
may be slight, moderate or, rarely, copious; or he may develop mild 
fever, nightsweats, cough and expectorate sputum containing tubercle 
bacilli. A physical exploration of the chest shows a typical lesion of 
moderate extent. Inasmuch as for several weeks the patient presents 
most of the symptoms and signs of progressive phthisis, even hectic 
fever, nightsweats, emaciation, etc., a grave or doubtful prognosis is 
rendered. 

But slowly the condition of the patient begins to improve; the fever 
abates, the cough is ameliorated or ceases altogether, the appetite 
improves and the patient gains in weight considerably, so that in a 
few months his weight exceeds that found before the onset of the 
disease. He considers himself cured. But a physical examination of 
his chest shows distinct and unmistakable signs of a smouldering 
tuberculous lesion in one apex; in fact, all the signs of active disease 
are there. Feeling well, the patient reenters his occupation and works 
quite efficiently, believing that the physician who declared him still 
actively tuberculous is an alarmist. I have had patients of this class 
who have been doing well for years and who came around to the office to 
"prove" it to me. Many are of the class who were admitted as 
advanced cases, and then discharged from sanatoriums as improved, 
or even "unimproved," and inquiry in later years shows that a large 
proportion remain in good condition and working, except for more 
or less pronounced dyspnea which annoys them. 

After some years the symptoms are gradually aggravated, they 
complain they have "caught a new cold," which is difficult to cure. 
The cough is persistent and exhausting, the dyspnea distressing, and 
they begin to lose in weight and strength progressively, presenting 
clearly the characteristic clinical picture of chronic phthisis with its 
usual complications, plus dilatation of the right heart, dyspnea and 
orthopnea. Physical exploration of the chest shows the usual clinical 
picture of cavitary phthisis, but there is in addition bronchitis, which 
is unusual in chronic phthisis. It differs, however, from chronic 
phthisis by the fact that fever is lacking, or at most some insignifi- 
cant elevation of temperature is noted at times. Xo nightsweats are 
present, or only slight, at the end of the disease. 



382 



FIBROID PHTHISIS 



Pleural Form of Fibroid Phthisis. — In the pleural form of fibroid 
phthisis, which has been graphically described by Williams, the 
patient usually gives a history of an attack of pleurisy with effusion, 
from which he has recovered after a longer or snorter illness, the fluid 
having been absorbed spontaneously or was aspirated. But ever since 
he has remained with a dry, hacking cough, productive of little or no 
sputum, and in spite of the great care he has been taking of himself, 
he has not succeeded in recuperating completely. Dyspnea is marked 
and increasing steadily in intensity. In many cases the cyanosis of 
the fingers and face is very pronounced. 

During recent years I have met with some cases of this type follow- 
ing artificial pneumothorax. A pleural effusion was slow in disappear- 
ing, and the gas inflations had to be discontinued. But the patient 
kept well on the road to recovery, remaining with a pleuropulmonary 
tuberculous lesion. 

Examination shows distinct immobility of the lower half of the side 
of the chest in which the effusion had taken place; some retraction of 
the chest wall and scoliosis, or kyphoscoliosis. Mensuration shows 
that the affected side has fallen in — the circumference being smaller 
than the unaffected side by more than one inch. Vocal fremitus is 
absent over that area. On percussion we find dulness, at times even 
flatness not unlike that over pleural effusion, which is at once sus- 
pected. This is apparently confirmed by the absence of the vocal 
fremitus and of any breath sounds, while in some we hear distant 
tubular or even cavernous breathing. There may be no adventitious 
sounds, but occasionally some medium-sized or large, moist and con- 
sonating rales and gurgles are audible during both phases of respira- 
tion. At times, distinct friction sounds, grating, and grunts are heard. 

On the unaffected side signs of pulmonary emphysema are found — 
hyperresonance and the inferior margin of the lung extends two to 
four inches lower than on the opposite side, owing to emphysema, and 
the pulmonary retraction and upward displacement of the diaphragm 
on the affected side accentuate it. Anteriorly, the border of the 
unaffected lung extends well over the sternum. 

The heart is almost invariably dislocated toward the affected side, 
which serves as a good sign of differentiation from pleural effusion 
with which it may be confounded, because in effusions the dislocation 
is invariably toward the unaffected side, if at all. In left-sided lesions 
we may find the apex as far out as the axillary line and one or two 
interspaces higher than the normal; in right-sided lesions the apex 
may be found at the xyphoid cartilage, or even farther to the right. 
It is in these forms of phthisis that acquired dextrocardia is at times 
found. It is due to traction of the heart by fibrous bands in the right 
pleura and lung and also to the pressure exerted by the vicariously 
emphysematous left lung. The shrinkage, as well as the fibrous bands 
in the lungs, also drag the diaphragm upward and when the right 
side is affected, the liver is also elevated. In the left side the stomach 



PROGNOSIS IN FIBROID PHTHISIS 383 

may be elevated along with the diaphragm. Pulmonary retraction in 
the left side also exposes the heart and brings it near the chest walls, 
where we may see it pulsating. These conditions may be made out by 
careful percussion, but in many cases the aid of skiagraphy is neces- 
sary to clear up mooted points. 

There are other clinical peculiarities which should be mentioned. 
Fever is usually absent throughout the course, excepting when due 
to some intercurrent affection. When we find a persistent elevation 
of temperature we may look for some complication, especially an 
infiltration of the opposite, hitherto unaffected lung. The cough, 
which was moderate for a long time, in some cases for years, becomes 
more and more severe and the amount of sputum brought up may be 
enormous. Both the cough and the expectoration may be influenced 
by posture — the patient coughs more when lying on one side, and is 
somewhat relieved when turning on the other side, just as in bronchiec- 
tasis. This, however, gives no clue as to which side is affected. The 
sputum contains tubercle bacilli in large numbers and is at times fetid, 
which is rare in other forms of phthisis. 

Hemoptysis, which is very frequent in other forms of fibroid phthisis, 
is less often encountered in the pleural form. But when occurring, it 
is apt to last for days or weeks, and at times it is copious. I have seen 
cases in which it was the cause of death of patients who were other- 
wise getting along very well. 

The dyspnea, which is a feature of all forms of fibroid phthisis, is 
more severe in this type because of the loss of lung tissue and the dis- 
placement of the heart. In fact, I have seen many cases in which the 
lesion in the lung was practically healed, or at least distinctly inactive, 
yet the dyspnea was severe and even unbearable. Another feature 
is cardiac palpitation, especially in left-sided lesions, which is apt to 
be so severe as to make life unbearable. 

In the terminal stages signs of cardiac dilatation set in — edema of 
the lower extremities, enlargement of the liver, cyanosis, etc., and the 
patient dies from asystole. In many cases complications are respon- 
sible for the final outcome — hemorrhage, which was already men- 
tioned, inanition due to laryngeal tuberculosis with dysphagia, amy- 
loid degeneration of the various visceral organs, etc. Tuberculosis 
of the previously unaffected lung may bring about a rapid course of 
the disease. 

I have observed that some of these cases, tuberculous in origin as 
they are, become purely bronchiectatic. The tubercle bacilli disap- 
pear from the sputum, but the patient continues to cough and expecto- 
rate large quantities of sputum which shows all the characteristics of 
sputum in bronchiectasis; in fact, the course is that of non-specific 
bronchiectasis after this occurrence. 

Prognosis in Fibroid Phthisis. — As regards duration of life, fibroid 
phthisis, though an active tuberculous disease and hardly ever cured, 
is more favorable than the other forms of phthisis, excepting abortive 



384 FIBROID PHTHISIS 

tuberculosis. It is among the fibroid patients that we find individuals 
who have been tuberculous for years. I have some who have lasted 
for twenty-five years, and Sokolowski reports one who lasted for more 
than forty years. While they are always ailing, many are still fit to 
pursue their vocation, and I have among my clientele some who have 
worked quite hard without long interruptions. 

In fibroid phthisis, the reparative processes of Nature are more 
active than the destructive tuberculous, and the patients are shielded 
from the extension of the caseating and softening processes, the 
fibrous tissue usually forming a wall around the lesion limiting its prog- 
ress and preventing the absorption of toxins, as is evident from the 
absence of fever, etc. Because of the pleural adhesions, the patients 
are shielded from such complications as spontaneous pneumothorax, 
which never occurs among them. When in my hospital practice I 
find a fibroid patient presenting the symptoms of spontaneous pneumo- 
thorax, it is soon clear that the rupture occurred in the lung which 
had been unaffected but recently showed a new lesion. 



CHAPTER XXIII. 
ABORTIVE TUBERCULOSIS. 

Natural Resistance Against Phthisis. — As was already shown, infec- 
tion with tubercle bacilli is harmless to the vast majority of civilized 
people; the lesion cicatrizes more or less quickly without producing 
distinct clinical symptoms. During childhood, when most infections 
occur, the morbidity and mortality from this disease are insignificant. 

We cannot recognize these mild or abortive infections clinically, 
except by the tuberculin test ; they probably pass as slight or severe 
" colds," grippe, bronchitis, etc. Xor do we know whether they are 
due to the inoculation by strains of bacilli of low virulence, considering 
the marked difference in virulence displayed by various strains of 
tubercle bacilli. The suggestion that they may be due to infection 
with bovine bacilli appears to have much in its favor, but this also 
has not been proved. 

We meet at times cases of abortive tuberculosis, i. e., patients in 
whom the disease, instead of pursuing the usual clinical course to its 
termination in death or recovery after several months 1 or years' illness, 
is aborted within a few weeks or months of indisposition. In other words, 
just as we at times meet with cases of abortive pneumonia, typhoid, 
scarlet fever, etc., so is there a form of pulmonary tuberculosis which 
is of relatively short duration and invariably terminates in recovery. 
In these cases the lesion is apparently circumscribed, of little activity, 
often altogether latent and quickly cicatrizes, and, when the patient 
dies from any other cause, it is found at the autopsy in the shape of 
more or less extensive scars located at the extreme apex, pleural 
adhesions, or even isolated fibrous or calcareous nodules which hardly 
caused any inconvenience to their owners during life. 

In the older works on phthisis, this form of tuberculosis is not men- 
tioned at all. In former days only advanced phthisis was recognized. 
But in recent years, since Bard 1 described the pathology and symptoma- 
tology of tuberculose abortive, many others have mentioned it more 
or less extensively. In the second edition of Cornet's 2 treatise, also 
in Bandelier and Ropke's book, we find it mentioned cursorily, while 
Piery 3 in his book devotes an extensive chapter to it. Bezancon 4 and 
the present author 5 have published papers on the subject of abortive 
tuberculosis. 

Abortive tuberculosis is responsible for a large proportion of "non- 

1 Formes cliniques de la tuberculose pulmonaire, Geneve, 1901. 

2 Die Tuberkulose, Vienna, 1907, p. 690. 

3 La tuberculose pulmonaire, Paris, 1910, p. 491. 

4 Bull. Soc. hop. de Paris, 1901, p. 933. 

5 Medical Record, 1913, lxxxii, 921. 
25 



386 ABORTIVE TUBERCULOSIS 

tuberculous" cases in sanatoriums — the lesion heals very quickly and 
it is often suspected that the patients were admitted through an 
error in diagnosis. Many of the patients who state that well-known 
physicians have considered them tuberculous at one time, but that they 
have none the less been healthy all along for years, have in fact been 
affected with the abortive type of the disease at the time the diagnosis 
was made. I have seen many patients who applied for admission to 
public sanatoriums and were passed by the admitting physicians as 
eligible incipient cases, but inasmuch as the institutions were over- 
crowded, they had to wait for weeks or months for vacant beds. 
When they were finally called, it was found that all the symptoms 
and signs of the disease had vanished. A large proportion of cases of 
"persistent colds," grippe, rhinopharyngitis, etc., are also abortive 
tuberculosis. If they were carefully studied, we would discover some 
physical signs in the chest substantiating this view. In fact, L. Napo- 
leon Boston 1 reports finding tubercle bacilli in cases of acute colds, 
influenza, bronchitis, etc., but the patients recovered without becoming 
tuberculous. Many of these were in fact abortive tuberculosis. 

Symptomatology of Abortive Tuberculosis. — The symptoms and 
signs of abortive tuberculosis are the same as those of incipient phthisis, 
but they never pass beyond that stage. In most cases it begins with 
the symptoms of a common "cold." After some exposure the patient 
begins to cough, has some fever, malaise, backache, etc., and is treated 
for coryza, grippe, tonsillitis, etc. But instead of ameliorating within a 
few days or a week, the symptoms persist for a month or two. In many 
cases the onset is marked by hemoptysis. The patient, who has felt 
quite well, or at most has coughed for a few days, suddenly feels some 
irritation in the throat and coughs out some blood or blood-streaked 
sputum. The bleeding may last for a few hours or days and either 
stops abruptly, or continues for a few days in the form of streaky 
sputum. Every physician has among his clientele patients who have 
expectorated blood years ago, but have felt well all along. While in 
many of these the hemorrhage was of extrapulmonary origin, as was 
already shown, in others it was due to abortive tuberculosis. 

When the thermometer is carefully and judiciously used, we find 
fever of a mild type; especially in the afternoon there is a rise of one 
or two degrees, and in the early morning there may be some subnor- 
mal temperature. In some cases that came under my observation I 
found the typical temperature curve of mild incipient phthisis, and 
there were many of the accompanying symptoms of hyperthermia — 
malaise, languor, pain in limbs, backache, etc. While the patient is 
not completely incapacitated, yet he feels tired during the afternoon, 
but recuperates in the evening or feels refreshed after a night's sleep. 
Nightsweats are rare, but in a few I have noted that they were drench- 
ing. The appetite is usually retained and when the patient is told 
to eat well and plenty, he finds no difficulty in following instructions. 

interstate Med. Jour., 1914, xxi, 330. 



PHYSICAL SIGNS OF ABORTIVE TUBERCULOSIS 387 

Cough is a constant symptom; though many state that they do 
not cough, careful inquiry reveals that they clear their throats in the 
morning. AYe often meet with dry, hacking cough which is an annoy- 
ance during the day, and keeps the patient awake during the night. 
Occasionally the cough is productive of glairy mucus, but the muco- 
purulent sputum of phthisis is never seen in abortive cases, unless 
there is some rhinopharyngitis. 

Most abortive cases are of the " closed 1 ' variety of tuberculosis, but 
now and then we meet with one showing tubercle bacilli in the sputum. 
The albumin reaction of the sputum is almost invariably positive in 
these cases, and I consider it of diagnostic importance. Edward G. 
Glover 1 found that the complement-fixation test for tuberculosis is of 
value in the determination of the nature of some of the dubious cases. 

In some, we meet with hoarseness lasting intermittently for a few 
hours during the day, or for several days in succession. 

Tachycardia is not a very frequent symptom, but we very often find 
instability of the pulse; the least exertion or excitement raises its 
rate to 90 or more Der minute. The blood-pressure is usually lower 
than normal. With the improvement in the condition of the patient 
both the pulse and the blood-pressure become normal again. 

Physical Signs. — The objective signs are those of incipient phthisis. 
Of course, when the lesion is limited and centrally located, we may 
not find any physical signs at all, and without hemoptysis and tubercle 
bacilli in the sputum, the diagnosis cannot be made. In all proba- 
bility the vast majority of tuberculous infections in man are of this 
character. They are aborted without revealing themselves in any 
way. But in those in whom the conglomeration of tubercles is large 
enough to alter the air content in a limited area of the lung, we may 
find signs on percussion and auscultation. 

A short note above and immediately beneath the clavicle is quite 
common. But this may be obscured by vicarious emphysema, hyper- 
function, or relaxation, of the surrounding lung tissue which may emit 
a hyperresonant note. Shortening of an apex, or narrowing of Kronig's 
resonant areas, is more common and can be easily made out with 
careful percussion. 

On auscultation we may hear feeble breath sounds over the site of 
the lesion, or rough, interrupted, cog-wheel breathing. Only the 
inspiratory murmur is usually altered, but I have seen cases in which 
the expiratory murmur was prolonged, and even bronchovesicular 
in character, indicating extensive infiltration, yet recovery went on 
speedily, showing that even a considerable focus may be aborted. 
This is confirmed by the large scars or encapsulated and calcified 
tubercles found at times while making autopsies on persons who died 
from causes other than tuberculosis. 

Adventitious sounds are not often heard, excepting in those who 
have had hemoptysis and in some grippal cases, in which dry crackles, 

1 Quarterly Jour. Med., 1915, viii, 339. 



388 ABORTIVE TUBERCULOSIS 

or crepitation, may be audible during inspiration and influenced by 
cough. Of course, to be of significance, these signs must be strictly 
localized at one apex, and constant for some time. They must also 
be differentiated from spurious rales, as well as from marginal sounds. 

Skiagraphy is of little value, as was already stated in Chapter XVII. 

Diagnosis. — These are the classical symptoms and signs of incipient 
phthisis, and when meeting with a case we are by no means certain 
as to the course the disease is likely to take. In fact, many abortive 
cases are admitted to sanatorium s where they are speedily cured, 
and they contribute no small portion of the statistical success of 
institutional treatment. 

In the progressive cases the lesion extends and the constitutional 
symptoms become more and more marked within a few months, while 
in the abortive forms the mild fever, cough, nightsweats, etc., abate 
within a few weeks or one or two months, and the physical signs dis- 
appear, or they are superseded by sibilation, and there may perma- 
nently remain a prolonged expiratory murmur over the affected apex. 
While in most cases the local impairment of resonance remains, and for 
this reason there are many persons in whom there are differences in 
this regard when the two apices are compared, I have observed that in 
some even this disappears, to be replaced by slight hyperresonance, 
due probably to hyperfunction, the result of vicarious emphysema of 
lung tissue around the cicatrix which was caused by the healing process. 

Without observing the patient for several weeks, and without an 
initial pulmonary hemorrhage, or tubercle bacilli in the sputum, 
abortive tuberculosis cannot be diagnosticated, because there always 
lurks a suspicion that it may have been a non- tuberculous apical lesion. 
There are, however, some points which may help us in recognizing 
this form of tuberculosis : When a patient with a distinct apical lesion 
has a good appetite and normal gastric function, gaining weight and 
strength as soon as he begins to take care of himself, here is a likeli- 
hood that the lesion may be aborted and cured within two or three 
months. However, this may prove deceptive at times. Some points 
which have helped me are the following: A slow pulse, not much 
influenced by exertion or excitement, speaks for a benign process. 
The initial hemoptysis of chronic phthisis, as was already stated, is 
usually preceded by cough, weakness, nightsweats, etc., for weeks 
before the bleeding, while in abortive cases this is rare — the hemoptysis 
comes like a thunderbolt out of a clear sky, without any premonitory 
symptoms and without any apparent exciting cause. In progressive 
cases the initial hemoptysis is usually more abundant, and always fol- 
lowed by fever of the type described above. In abortive tuberculosis 
the temperature remains normal at times, but usually it is slightly 
elevated, 1° or 1.5° F. for a couple of weeks. Initial hemoptysis of 
tuberculous origin without high or moderate fever, and without tachy- 
cardia, weakness, languor, etc., points to an abortive lesion. 

In the majority of cases, however, only careful observation of the 
course of the affection is decisive. 



CHAPTER XXIV. 
PULMONARY TUBERCULOSIS IN CHILDREN. 

General Characteristics of Tuberculosis in Children— In children 
infection with tubercle bacilli, if it causes active disease at all, is 
usually followed by a generalized morbid process with implication of 
the lymphatic glands. This characteristic is the more accentuated 
the younger the child. In fact, in all infectious diseases we may note 
that the reaction of the lymphatic glands is intense in children. The 
glands are particularly sensitive to tuberculosis. 

The localized disease of the lungs peculiar to phthisis in adults, 
or in the bones and joints, characteristic of early childhood, is hardly 
ever seen in infants. In infants tuberculosis is an acute, general infec- 
tion, like typhoid or septicemia, and when the bacilli localize them- 
selves by metastasis in any part, they produce lesions akin to those 
of pyemia. 

Because of the implication of the glandular system, especially the 
intrathoracic glands, it was assumed by many authors that infection 
in children is invariably accomplished by inhalation of the bacilli. 
The microorganisms are deposited in the lungs, and when attempting 
to invade the blood, they are retained by the lymphatic glands. When 
the localization of the lesion was found in the mesenteric glands, it was 
clear that ingestion of the bacilli was the channel of entry, and this was 
confirmed by the fact that in mesenteric tuberculosis bovine bacilli 
were often found. 

But we have seen that this is not necessarily the case. Entering 
via the digestive tract, the bacilli may reach the tracheobronchial 
glands with as much ease as when entering via the respiratory tract. 
Behring and Calmette and their school maintain, in fact, that all 
tuberculosis, especially in children, is lymphogenic and hematogenic 
(see p. 50) . 

From the facts presented in the chapter on phthisiogenesis it is 
clear that tuberculosis during infancy and childhood is hematogenic, 
irrespective of the portals of entry of the bacilli. A study of the rates 
of mortality during the various ages of life confirms this view. As 
will be seen from the accompanying diagram (Fig. 65), pulmonary 
tuberculosis is a frequent cause of death in infants under two years 
of age; between three and fourteen years of age comparatively few 
succumb to this form of the disease ; only after fifteen years of age does 
it become very frequent and remains so until the age groups above 
eighty years. We know from clinical experience that, when occurring 
during the first two years of life, pulmonary tuberculosis is almost 
invariably an acute disease, and the chronic type is unknown at this 



390 



PULMONARY TUBERCULOSIS IN CHILDREN 



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TUBERCULOSIS DURING INFANCY 391 

age. On the other hand, all other forms of tuberculosis, including that 
of the glands, bones, joints, serous cavities, especially the meninges, 
and the intestines; in short, the hematogenic forms of tuberculosis, 
cause death most frequently during the first four years of life and are 
comparatively uncommon as a cause of death after the fifth year of life. 
It is thus clear that acute tuberculosis, as well as the hematogenic 
forms of this infection, have a different age incidence when compared 
with chronic phthisis, the disease which creates the main problem. 
Moreover, as was already shown, during the years when most of the 
human infections take place, between the second and the fourteenth, 
the mortality from all forms of tuberculosis is comparatively low; 
even hematogenic tuberculosis as a cause of death maintains the same 
rate throughout the rest of human life. It also shows that phthisis, 
which is a common cause of death in adults, is not necessarily pre- 
ceded by infection with tubercle bacilli immediately before the disease 
manifests itself by symptoms. It shifts the problem of infection from 
the adult to the child. 

TUBERCULOSIS DURING INFANCY. 

We have shown that the child is born free from tuberculosis, and that 
infection, if it takes place at all, occurs postpartum. Virchow, whose 
autopsy experience was as immense as that of any physician, stated that 
he never encountered a case of fetal tuberculosis. Infection in an infant 
is therefore invariably primary and almost always followed by symptoms 
of disease. Indeed, as we have already shown, there are cases on record 
in which infants brought into contact with a consumptive for an hour 
or so developed tuberculous disease of a malignant type. When the 
infection is massive, acute general tuberculosis with implication of the 
glandular system and often of the lungs is almost invariably caused. 

The infant's organism behaves after a primary infection just as the 
very susceptible guinea-pig; the reason being that there is a primary 
infection of a body which has not yet been immunized by a previous 
mild infection. These cases are mostly seen in infants who live with 
tuberculous persons — the father, mother, sister, brother, or nurse being 
tuberculous and, in handling the infant, an opportunity is afforded to 
transmit the disease. Thus, Combe 1 found a family history of tuber- 
culosis in 90 per cent, of his cases, if the word "family history" 
included all persons who lived in intimate contact with the family. 
Clinicans have found that in doubtful cases a careful family history is a 
great aid in diagnosis, provided it includes not only the father and the 
mother, but also brothers, sisters, servants and relatives and acquain- 
tances who come to the house and in contact with the infant. There 
is evidence tending to show that in some cases, though in less than is 
generally supposed, the infection is derived from bovine bacilli through 
milk from tuberculous cows. 

1 Le Nourisson, 1916, iv, 1. 



392 PULMONARY TUBERCULOSIS IN CHILDREN 

In many cases no exciting cause, except the source of infection, 
can be traced. In others some acute endemic disease of infancy is 
found to have produced a state of allergy. This is especially true of 
measles and whooping-cough, but any of the other contagious diseases 
of infancy may reduce the vitality and resisting powers of the infant 
and infection is then followed by the characteristic acute form of 
tuberculosis. 




Fig. 66. — A primary cheesy focus the size of a lentil in a bronchus of the left lower 
lobe with miliary and conglomerate tubercles of the regional peripheral atelectatic lung. 
Caseation of the bronchopulmonary and lower tracheobronchial glands in the region 
of the right lower lobe. The glands on the left side are free. (Anton Ghon.) 

The period of incubation of tuberculosis in infants has not been 
exactly determined. In the few cases reported by Koch and Knipfel- 
macher 1 it appeared to be about seven weeks. Reuben 2 in New York 
found it to be from five to six weeks. 

Symptoms. — The symptoms depend on the mode of onset and on 
the parts of the body which bear the brunt of the infection. In those 

1 Ztschr. f Kinderheilk., July, 1915. 

2 Arch. Pediat., 1916, xxxiii : 171. 



TUBERCULOSIS DURING INFANCY 393 

in whom tuberculosis follows in the wake of another disease, like 
whooping-cough, measles, etc., there are usually symptoms of broncho- 
pneumonia or meningitis, which cam- off the patient within a few days, 
a week or two. In addition to the symptoms and signs of broncho- 
pneumonia, there are often found enlargement of the spleen and liver 
and swelling of the superficial glands, the cervical, axillary, inguinal, 
etc. This form of acute tuberculosis is best seen in cases of tubercu- 
lous disease engendered by inoculation, as in infection of the wound 
after ritual circumcision. • Arluck and Wincouroff, 1 and Holt 2 have 
recently described such cases in detail. 

In those in whom the disease is slower in development, athrepsia is 
seen. It is noted that the child does not thrive despite the fact that its 
nourishment leaves little or nothing to be desired and the gastro- 
intestinal functions are fairly normal. There may be no fever at all. 
Still the emaciation proceeds frightfully. In some cases the emacia- 
tion consumes nearly all the subcutaneous adipose tissue and the thin, 
pale skin is stretched over the atrophied, softened, and bent bones. 
These infants usually have long hair on the back between the shoulder 
blades and on the extremities; their eyes are sunken and the eyelashes 
are unusually long. In a large proportion, over 20 per cent, according 
to T. C. Hempelmann, tuberculides are found on the body. Finally 
the temperature begins to rise and may reach very high, and they 
succumb to symptoms of septicemia or meningitis. 

Examination of the chest may not show any changes, while in some 
we may find areas of defective resonance, bronchial breathing, or rales. 
In infants limited and circumscribed lesions are very difficult of locali- 
zation because we have no assistance on their part while exploring the 
chest. 

Cough may be absent altogether, but in some cases we meet with a 
peculiar cough caused by pressure of enlarged glands on the bronchi, 
or on the nerves passing through the chest. Eustace Smith 3 first 
described this cough as spasmodic, occurring irregularly in paroxysms 
like those of pertussis, lasting only a short time and ending sometimes, 
though rarely, in a crowing inspiration. This cough has since been 
differently described by various authors. Schick 4 describes a respira- 
tory crow, or stridor, resembling the sound heard in asthma and in 
capillary bronchitis. It can, however, be distinguished from the latter 
by the fact that in asthma the cough is paroxysmal while the stridor 
in bronchial adenopathy in infancy is continuous, lasting without 
change for weeks and months. The French have described it as toux 
coqiteluchoide, and Strieker compares it with the bark of a hoarse 
puppy. 

In many cases dyspnea is observed. It may be inspiratory or expira- 

1 Beit. z. klin. d. Tuberkulose, 1912, xxii, 341. 

2 Jour. Am. Med. Assn., 1913, lxi, 99. 

3 Wasting Diseases of Infants and Children, London, 1878. 

4 Verhandl. d. Ges. f. Kinderheilk., xxvi, 1909, 121. 



394 PULMONARY TUBERCULOSIS IN CHILDREN 

tory, though in infants it is most commonly expiratory. It is best 
differentiated from dyspnea due to trouble in the larynx by the fact 
that in adenopathy the voice remains clear. 

In most of these slow cases the cachexia progresses until finally 
the child succumbs to some intercurrent disease or to tuberculous 
bronchopneumonia. On rare occasions a softened gland ruptures 
into a bronchus causing aspiration pneumonia. A relatively large 
proportion end with tuberculous meningitis. Investigations made 
by the writer 1 in children under six years of age living a tuberculous 
milieu in New York City have shown that 16 per cent, succumb to 
meningitis, as against only 2.6 per cent, among the general population. 

Other infants may be anemic and underfed for months. They do 
not thrive in spite of all efforts to improve their nutrition. Finally, 
the marasmus assumes an acute character, the fever rises and they 
succumb to exhaustion or more commonly to some intercurrent disease. 

Diagnosis. — It is clear that the diagnosis of tuberculosis in infancy 
is not an easy matter. Hamburger's 2 advice should be followed by 
all who have infants under their care : Think of tuberculosis in every 
case in which no other diagnosis can be made. This dictum is shared by 
nearly all other pediatrists who have given thought to the problem. 
Tubercle bacilli cannot be discovered because infants do not expec- 
torate. Holt has, however, often found them by swabbing the throat 
with a pledget of cotton. A positive tuberculin (von Pirquet) reaction 
in an infant under one year is sufficient to clinch the diagnosis. Un- 
fortunately during the course of measles or whooping-cough and in 
tuberculous meningitis, the tuberculin reaction is apt to be negative, 
despite the presence of tuberculous infection. 

Prognosis. — The prognosis of tuberculosis in infancy is very gloomy. 
In fact, it may be stated that the younger the infant the more unfav- 
orable the prognosis. During the first three months of life hardly 
any survive infection; the vast majority of those infected during the 
second three months of life succumb to the disease or to some inter- 
current infection; the outlook for infants between six and eighteen 
months is very unfavorable when infected with tuberculosis. 

In this gloomy prognosis nearly all authorities agree: Holt 3 holds 
that the outlook for a young child with general or pulmonary tuber- 
culosis is always bad; Schlossmann 4 says that he does not know of a 
single case in an infant which resulted in recovery; von Pirquet 
maintains that 90 per cent, of infants infected during the first year of 
life perish; Louis Guinon 5 says that before the fourth year of life 
tuberculosis is always fatal; and Monti 3 says that he never saw a case 
of tuberculosis in an infant under two years recover. 

i Arch. Pediat., 1914, xxxi, 197. 

2 Brauer, Schroder, and Blumenfeld's Handbuch d. Tuberkulose, Leipzig, 1915, v, 6. 

3 Diseases of Infancy and Childhood, 5th edition, p. 1004. 

4 Pf andler and Schlossmann: Diseases of Children, Philadelphia, 1912, ii, 632. 

5 La prat, des mal. des enf., Paris, 1911, iv, 479. 

6 Ueber Tuberkulose. Kinderheilkunde in Einzeldarstellungen, 1901. 



TUBERCULOSIS DURING EARLY CHILDHOOD 395 

It appears to be the consensus of opinion of most pediatrists that all 
tubercles during the first two or three years of life are active, that the 
lungs show no tendency to limitation of the disease, and that there are 
no reparative processes to be noted when examining the lungs of 
children who succumbed to tuberculosis. No cicatrization or calci- 
fication is to be observed. 

The corollary has been drawn that all infants showing signs of 
infection with tubercle bacilli — a positive von Pirquet reaction — are 
doomed. The writer cannot agree with this. We have followed 
infants showing positive von Pirquet reactions during the first three 
months of life growing into healthy children. It appears that the 
dangers of developing active tuberculous disease and the acuteness of 
the process engendered are in inverse ratio to the age at which the 
infection takes place. The younger the infant the more unfavorable 
the prognosis. But even among very young infants cicatrization and 
calcification of the lesion may occur. In another place I have col- 
lected evidence showing that such healed lesions were found at 
autopsies made on infants who died from other causes. The writer 
has observed numerous infants living with their tuberculous parents 
become infected with tuberculosis, yet they grew into healthy children. 
Some have been followed for more than ten years. Mark S. Reuben in 
New York had under his care from 1909 to 1916, for shorter or longer 
periods, 23 infants who gave a positive tuberculin reaction. Xine of 
the 23 infants who became infected during their first year of life kept 
up in good health for from one to five years. T. C. Hempelmann 
studied the fate of 130 infants under two years of age with pulmonary 
tuberculosis. He found that the mortality among the infants under 
one year of age was 78.7 per cent.; from one to two years of age, 57.4 
per cent.; and for the two years, 68 per cent. 

It is thus clear that while tuberculous infection during infancy is 
very serious, it is by no means hopeless, as some writers have stated. 
At least one out of three survives. 



TUBERCULOSIS DURING EARLY CHILDHOOD. 

Significance of Tuberculosis during Childhood. — In our study of the 
epidemiology of tuberculosis we have seen that the child is born free 
from tuberculosis but that soon after birth, on coming into contact with 
tuberculous individuals or their discharges, or consuming milk from 
tuberculous animals, it is infected with tubercle bacilli. We have 
also shown that during the first year of life relatively few — between 
5 and 10 per cent. — are infected with tubercle bacilli. During the 
second year more are infected, and the number of infections keeps on 
growing so that at the age of fifteen over 90 per cent, show unmistak- 
able signs of harboring tubercle bacilli in the body. A study of the 
mortality from tuberculosis according to age groups has shown that 



396 PULMONARY TUBERCULOSIS IN CHILDREN 

the mortality from this disease is very high during the first two years 
of life. Considering the malignant clinical forms of the disease which 
have been described above, the reason is clear. But beginning with 
the third year the number that succumbs to this disease is very small 
and this low mortality keeps on until the fifteenth year, when there is 
another increase which keeps on rising, so that from the twentieth 
year onward the maximum has been reached, which keeps up until far- 
advanced age. 

It is thus clear that during the years when most infections with 
tubercle bacilli take place, the mortality is at its lowest. It is also clear 
that if infection is to take place, which we have shown to be inevitable 
for those living in large industrial towns and coming into contact with 
many people, it is best that it should occur during childhood. Appar- 
ently, during this age period death due to tuberculosis is exceptional. 
This point will be discussed again when speaking of the prophylaxis 
of tuberculosis. 

Infection and Morbidity. — We must again emphasize the difference 
between infection with tubercle bacilli and disease due to this micro- 
organism. It appears that the vast majority of children infected with 
tubercle bacilli do not show any clinical manifestation of disease, 
otherwise over 50 per cent, of children in la^ge cities would be sick and 
in need of careful treatment; at the age of ten over 75 per cent, would 
be sick and in need of dietetic, specific, institutional, or climatic treat- 
ment. Scientific tests prove conclusively that the vast majority of 
children have been infected, and but few show clinical manifestations 
of disease; hence the bulk of infections at that age cause no disease, 
and may be disregarded by the clinician. Some, however, do show 
clinical manifestations of disease. 

Tuberculous Tracheobronchial Adenopathy. — Excluding tuberculosis 
of the bones and joints and the meninges, the bulk of the tuberculous 
morbidity is caused by tuberculosis of the glands, especially the cervi- 
cal and the intrathoracic. In most of the children having enlarged 
tuberculous glands the symptoms are negligible, or there are no clinical 
manifestations at all. Thus we often discover enlarged glands on the 
neck or in the thorax of children who are in excellent condition of 
health. In some we find the glands enlarged for some time, then there 
is recession, the swelling goes down or disappears, while the children 
kept up their activities at school, and were none the worse for the 
experience. In others, the appearance of the glands is concurrent 
with the occurrence of some disease, like measles, scarlet fever, whoop- 
ing-cough, etc.; they remain enlarged during convalescence, but after 
complete recovery they recede or disappear permanently, or may 
return when some other exciting cause is again operative. We may 
thus see in many children a tendency to enlargement of the glands 
whenever an exciting cause- is operative, but the innate forces of 
resistance are at work and recovery takes place in a short time, spon- 
taneously, or after some treatment has been instituted. This class of 



TUBERCULOSIS DURING EARLY CHILDHOOD 397 

children needs no special treatment beyond life in healthy surroundings 
and good nourishment. 

Symptoms of Glandular Tuberculosis in Children. — In others the 
appearance of glandular tuberculosis is accompanied, often preceded, 
by symptoms which are troublesome, and need careful study for their 
recognition. 

Of these symptoms the following are the most important: Emacia- 
tion, fever, nightsweats, anemia, anorexia, etc. 

Emaciation. — A healthy child gains in weight constantly, and if it 
is regularly weighed, say every month, it will be found that the scale 
registers more than at the preceding weighing. While in normal 
adults a lack in this direction is not necessarily an indication of disease, 
because they may have reached their normal standard, or even exceeded 
it, with children conditions are different. Commensurate with their 
gain in height, there must be a gain in weight in children of school 
age. It is known as the normal increment in the size of the body. 
When a child does not gain in weight it is, with few exceptions, an 
indication of disease. 

To ascertain this gain in weight various tables have been prepared 
by anthropometrists, and reproduced in many text-books on pediatrics. 
But I want to warn the practitioner against comparing the weight of 
a child under his care with that given in any of these tables. To begin 
with, the weight given in the table for each age is an average of a large 
number of children, and averages permit variations that are nprmal. 
The weight of the child depends solely on its height, and there are 
perfectly healthy children and adults who are short of stature. 

What the physician should look for is a steady gain. If this is not 
found, it is clear that the child is sick. At any rate, it demands an 
explanation. In many cases it may be due to some intercurrent 
non-tuberculous disease. But it should be found and treated. When 
ive find that a child is not gaining in weight for several months, it is 
equivalent to a steady loss in an adult. If there is no morbid condition 
to account for it, tuberculosis may safely be suspected as the cause. 
A careful physical examination will, in the majority of cases, reveal 
enlarged intrathoracic glands. 

An exception is to be mentioned. Infants may be suffering as a 
result of tuberculous infection and show no signs of emaciation for 
a long time. This is evident from the fact that tuberculous menin- 
gitis, or bronchopneumonia, often attacks well-nourished infants. In- 
fantile tuberculosis, unless the gastro-intestinal tract is affected, does 
not always lead to cachexia. 

With the emaciation there is often to be observed anemia, mani- 
festing itself in marked pallor of the skin and mucous membranes, 
though an examination of the blood may not disclose any definite 
changes in its cytology. 

Fever. — Whenever tuberculous glands cause trouble there is a rise in 
temperature. Hamburger's conception of tuberculous disease supplies 



398 PULMONARY TUBERCULOSIS IN CHILDREN 

the theoretical basis for the fever in these cases. He looks upon all 
clinical exacerbations of tuberculosis as spontaneous tuberculin reac- 
tions due to a sudden flooding of the body juices with tuberculin, 
producing the same symptoms as we produce artificially by injecting 
tuberculin. In other words, the fever is a manifestation of auto- 
inoculation. 

The healthy child's temperature oscillates between 98.8° and 99.8° 
F. Whenever it rises above these limits, it is to be considered patho- 
logical and an explanation is to be sought. If no cause can be found 
for elevation of temperature, which is observed persistently for several 
weeks, tuberculosis is to be thought of. In most cases it will be found 
that, in addition to the thermometrical findings, there are also symp- 
toms of hyperthermia, such as anorexia, languor, etc. The child may 
feel refreshed and lively during the morning hours, but late in the 
afternoon it is flushed, tired, and seeks rest. 

In evaluating thermometrical findings it must always be remem- 
bered that the fluctuations in the temperature are much more pro- 
nounced in children than in adults. Thus E. Wynne 1 found that among 
1000 children 261 had temperatures of 99° F. or over, and of these, 
112 presented no obvious pathological condition to account for the 
hyperthermia. Mary E. Williams 2 found among 1000 school children 
between the ages of twelve and fourteen years that no less than 55.5 
per cent, had temperatures of 99.6° F. and higher. 

There are two reasons to account for the oscillations of the tem- 
perature in children. The heat center is more apt to be disturbed by 
slight factors than in adults, as is shown by the fact that nearly all 
pathological conditions produce higher fever in them than in adults. 
Then, there are so many subacute or chronic conditions which produce 
mild fever in children, that it would be wrong to base a diagnosis of 
tuberculosis on thermometrical findings alone. But when the tem- 
perature is found elevated persistently for several weeks in a child, and 
other symptoms of tuberculosis are present, while no other cause 
can be discovered, the patient is to be kept under careful observation. 
A difference of more than 1.5° F. between the minimum and maximum 
temperature of the day, when persistent, points to tuberculosis, when 
no other cause can be found. 

Nightsweats. — As a symptom of tuberculosis in children night- 
sweats have not the same significance as in adults. Many non-tuber- 
culous children sweat during the night. In a study of the physiological 
phenomena of sleep in children, Czerny 3 found that the intensity of 
evaporation from the skin goes hand-in-hand with the depth of the 
sleep. At the time when sleep is most intense, at its maximum, the 
skin is warm and moist, and usually profuse perspiration on the face is 
noted. This is not to be considered pathological. 

1 Public Health, 1913, xxvi, 136. 

2 Lancet, 1912, i, 1192. 

3 Jahrb. f. Kinderheilk., 1892, xxxiii, 22. 



TUBERCULOSIS DURING EARLY CHILDHOOD 



399 



To be of diagnostic significance, nightsweats in children must appear 
during the second half of the night and be so profuse as to soak 
through the bedclothes. Even in such cases they may not be pathogno- 
monic of tuberculosis; the possibility must always be borne in mind 
that they may be of nervous origin, especially in older children. At 




Fig. 67. — Diagram showing greater number of glands located on the right side. 



any rate, nightsweats are often absent in tracheobronchial adenopathy, 
though with each exacerbation of the symptoms of activity they are 
to be observed. 

In tuberculous bronchopneumonia in children nightsweats are the 
rule, but in non-tuberculous cases they are often a prominent and 
annoying symptom. 



400 



PULMONARY TUBERCULOSIS IN CHILDREN 



Cough. — Cough is another symptom of active tuberculosis in children. 
It is non-productive, unless the sputum is derived from the naso- 
pharynx, which is not uncommon. Hamburger says that it is never 
absent in active, incipient cases, and when a cough lasts more than a 
week the possibility of tuberculosis should be considered and a thorough 
search for other symptoms and signs of the disease should be inaugu- 




Fig. 68. — Tuberculosis of cervical and axillary lymph nodes in an eight-year-old boy 

(Carr.) 



rated. In advanced stages of the disease cough may be lacking, espe- 
cially when there is an arrest in the progress of the disease, which is not 
infrequently the case in children between eight and fourteen years of 
age. But even in these cases we meet with frequent exacerbations of 
the disease when the child coughs more or less. 

We must, however, emphasize that in children over three years of 
age cough is only of significance as a symptom of active tuberculosis 



TUBERCULOSIS DURING EARLY CHILDHOOD 



401 



when other symptoms are present, especially emaciation. When 
a child thrives, despite a chronic cough, it will be found that there is 
another cause, especially chronic or subacute catarrh of the nose and 
throat, particularly during the winter months. Asthma also is often 
a cause, and so is chronic bronchitis of the upper lobe, though we 
must be careful when finding unilateral bronchitis, which is almost 
invariably tuberculous. Signs of bronchitis of the lower lobe, even if 
unilateral, point to bronchiectasis and hardly ever to tuberculosis. 
Bronchiectasis is very common in children. 

The paroxysmal and the brassy cough of infants, as well as the 
expiratory stridor of infants, have already been described. 

Children presenting any or all of 
these symptoms — emaciation, fever, 
night sweats, cough, etc. — require a 
careful physical examination and if 
these symptoms are due to active 
tuberculosis, we almost invariably 
find local tuberculous changes — that 
the glands are affected — except in 
those over eight years of age, among 
whom localized pulmonary tubercu- 
losis of the same character as in 
adults may be found. 

In many cases we note that 
despite the fact that the physical 
development of the child is decid- 
edly inferior, its mental capacities 
are above the average. These chil- 
dren are often precocious, excep- 
tionally good pupils at school, and 
if with artistic inclinations, they 
may be excellent musicians, etc. 
On the other hand, in quite a large 

proportion of cases the smouldering tuberculous process has quite the 
opposite effect — the child is backward in his studies, lazy and listless. 

Cervical Adenopathy. — Among the glands most frequently affected 
in active tuberculosis in childhood the most important are the 
cervical and the tracheobronchial. The former group is easily exam- 
ined because when enlarged we can see and palpate them and ascertain 
their condition. 

If we should take enlarged cervical glands as an indication of active 
tuberculosis in children, we would find very few raised under adverse 
hygienic and economic conditions who are free from the disease. Thus, 
among 692 children of tuberculous parentage examined by the author, 
469, or 67.8 per cent., had swollen cervical glands. A careful examina- 
tion of children attending dispensaries show T s that between 50 and 
75 per cent, have palpable cervical glands. Most of them are due to 
26 




Fig. 69. — Tuberculosis of the 
submaxillary glands. 



402 PULMONARY TUBERCULOSIS IN CHILDREN 

carious teeth, hypertrophied tonsils, stomatitis, eczema or pediculi of 
the scalp, etc. That they are no indication that the intrathoracic 
glands are also swollen may be concluded when we bear in mind that 
anatomically the two groups have no direct connection, as has already 
been shown (p. 50). 

Some distinction may, however, be made between enlarged cervical 
glands due to tuberculosis and those due to other causes. When the 
tumors in the neck are ve*y large and persistent, showing little ten- 
dency to caseation and suppuration, they are almost invariably tuber- 
culous. Of greater importance is enlargement of the supraclavicular 
glands, which drain the parietal pleura, especially when found unilat- 
erally. This speaks for tuberculosis of the apical pleura, as will be 
shown when discussing pleurisy. Ranke 1 has pointed out another 
characteristic of tuberculous cervical glands. They are apt to swell 
up at irregular intervals and retrogress again after remaining large for 
a few days or weeks, and each time the swelling increases there is an 
increase in the intensity of the constitutional symptoms. During the 
retrogression they become smaller, harder, lose their roundish contour 
and become fixed to the surrounding tissues. But while this sign is 
undoubtedly of value, it has failed me in several cases. 

Physical Signs of Tracheobronchial Adenopathy. — The best that 
can be said about the physical diagnosis of tracheobronchial adenopathy 
is, that it is very indefinite; at any rate, all the criteria taken for 
proof of the existence of enlarged glands within the thoracic cavity do 
not enlighten us whether the process is active and demands active 
treatment, or is merely an innocuous enlargement of the glands of no 
clinical importance, as it actually is in the vast majority of cases. Judg- 
ing by the anatomical relations of these glands, it is clear that they 
must attain some size before they become discoverable by percussion 
and auscultation of the chest. But that they often do attain large 
dimensions may be assumed when we consider the size attained by the 
cervical glands at times. 

This group of glands includes those located around the trachea and 
bronchi, mainly in front of the bifurcation of the trachea. Pathologic- 
ally, it has been found that those around the right bronchus are liable 
to attain very large dimensions and produce symptoms and signs of 
the disease. From the practical standpoint, in addition to the anterior 
and posterior mediastinal glands, there are three groups of glands 
which may become swollen because of tuberculous infection: At the 
bifurcation of the trachea we have the tracheobronchial lymph nodes; 
along the main bronchi there are the bronchial lymph nodes; and at 
the hilus of the lungs there are the pulmonary lymph nodes, which also 
surround the bronchi, and communicate though lymph spaces with 
the parenchyma. In fact, all these glands receive their lymph from 
the pulmonary tissue and the bronchi. Considering their anatomical 

iMiinchen. med. Wchnschr., 1914, lxi, 2099, 



TUBERCULOSIS DURING EARLY CHILDHOOD 403 




Figs. 70 and 71. — Composite drawings showing the relationship of the bronchial 
glands to the thoracic wall in the adult. The glands are according to Sukiennikow, and 
the trachea and bronchi are after Blake (Am. Jour. Med. Sc, 1899, cxvii, 320). In the 
child the trachea bifurcates at about the level of the intervertebral disk between the 
fourth and fifth thoracic vertebrae, which corresponds nearly to the tip of the fourth 
thoracic spine. This is about opposite the articulation of the third costal cartilage 
anteriorly. (Stoll.) 



404 PULMONARY TUBERCULOSIS IN CHILDREN 

relations it is clear that when enlarged, they may exert pressure upon 
the bronchi and trachea, as well as on the nerves and bloodvessels 
passing through the chest. They may produce symptoms because of 
pressure exerted on the vagus and recurrent laryngeal nerves and the 
superior vena cava. They may even press upon the phrenic nerve, 
the arch of the aorta, innominate veins, etc. But this is exceptional 
despite the fact that text-books give so many signs revealing pressure 
on the various structures. The anatomical relations of these glands 
are shown vividly in the illustrations (Figs. 70 and 71, page 403) from 
Stoll, 1 based on Sukiennikow's 2 anatomical researches. 

Inspection. — On inspection the thorax is often found deformed in 
those who have had enlarged glands; indeed, some of the deformities 
produced by the intrathoracic glands are difficult to differentiate from 
the changes produced by early rickets. In some cases we find the 
typical phthisical thorax, the habitus phthisicus — a long, narrow chest 
with the ribs slanting downward at an acute angle, and narrow inter- 
costal spaces. Children with such chests have passed through 
several attacks of glandular enlargement and may, at the time 
of examination, be in fair health. In many we see what Stoll calls the 
"hilus dimple." If the breath is held at the end of inspiration there is 
seen an apparent retraction on one or both sides in the second inter- 
space. Owing to lack of expansion of one apex, the chest wall lags with 
inspiration. In old cases this "dimple" may remain permanently, 
owing to pleural adhesions or cicatrization of the peribronchial tissues 
at the hilus (Figs. 72 and 73). 

This phthisical chest, which some authors consider predisposing to 
phthisis, is in fact proof that the patient has been tuberculous for a 
long time, and in children it is proof that the thoracic glands have 
been enlarged. In our investigations of the form of the chest in children 
of tuberculous parentage, we found that at birth the chest is almost 
invariably normal, and only when tubercle affects the intrathoracic 
viscera are changes in its form produced. In some cases unilateral 
bulging of the chest wall is noted, especially the first two interspaces 
near the sternum. 

Enlarged veins are often visible on a chest containing enlarged 
glands. They are usually seen on the upper part of the thorax, mostly 
bilateral though not symmetrical, and at times unilateral. In my own 
cases, 37.5 per cent, of children with tracheobronchial adenopathy had 
enlarged and visible veins on the thorax, and of these, three-fourths 
were unilateral. Of those in whom the diagnosis of latent tuberculosis 
was justified, or in whom it was strongly suspected, 25 per cent, showed 
this sign, while among the manifestly healthy only about 1 per cent, 
had enlarged veins on the thorax. Stoll found enlarged and visible 
veins on the thorax in 92 out of 173 cases; of these 50 per cent, were 
tuberculous. 

1 Am. Jour. Med. Sc, 1911, cxli, 83; Ibid., 1914, cxlviii, 369; Am. Jour. Dis. Children, 
1912, iv, 333. 

2 Berl, klin. Wchnschr., 1905, xi, 316, 347, 369. 



TUBERCULOSIS DURING EARLY CHILDHOOD 405 

It thus appears that this is a fair sign of compression of the main 
trunks of the intrathoracic veins by enlarged glands or adherent 
pleura. My general experience, however, urges me against hasty 
diagnosis based on this sign alone. It is met with in many healthy 
children, especially such as have a delicate and transparent skin, and 
also in anemia. In adults, it is often seen in women during lactation, 
when it may be unilateral, and in persons suffering from non-tuber- 
culous affections of the bronchi, lungs, and pleura, especially chronic 
bronchitis, asthma, and pulmonary emphysema (see p. 265) . 




Fig. 72 Fig. 73 

Figs. 72 and 73.— The " hilus dimple." (Stoll.) 

Percussion. — A great deal has been written about percussion as an 
aid to the diagnosis of tracheobronchial adenopathy. But as a matter 
of fact there are many children with undoubted enlargement of these 
glands in whom the percussion note elicited over every part of the chest 
is practically normal. When we consider the topographical position 
of the bifurcation of the trachea, it is clear that the glands must become 
very large to produce dulness anteriorly or posteriorly over the surface 
of the chest. The various special methods like Koranyi's 1 vertebral 
percussion, which has been elaborated in this country by John C. 
Da Costa, 2 do not give satisfaction. In many cases, however, there is 
found paravertebral dulness on light percussion. The areas that may 
be found affected correspond to the hilus — the interscapular space, 
especially the right, and anteriorly in the upper two interspaces 

1 Ztschr. f. klin. Med., 1906, lx, 295. 

2 Am. Jour. Med. Sc., 1909, cxxxviii, 815; 1913, cxlvi, 660. 



406 PULMONARY TUBERCULOSIS IN CHILDREN 

near the sternum. To elicit this, very light percussion is necessary 
because of the thinness and resilience of the thoracic walls in the child. 
It may be found when the glands are not very much enlarged; then it 
is due to the engorgement of the bloodvessels and lymphatics which 
exists in the region of the hilus during the course of certain acute 
infectious diseases. It is the collateral inflammation described by 
Tendeloo. 1 

This defective resonance is only rarely bilateral. Anteriorly it must 
be differentiated from the dulness due to an enlarged thymus. The 
latter is usually beneath the sternum, while in bronchial adenopathy 
the dulness is mainly at the side of that bone, mostly to the right. 
We must mention that there is normally an oval area of dulness between 
the first and fifth thoracic vertebrae, extending an inch to two outward 
on each side of the spine, to which William Ewart 2 has called attention. 
But in cases of glandular enlargement it is usually unilateral — one 
interscapular space is dull. I have seen a few cases in which enlarged 
thoracic glands produced dulness all over one side of the chest. Another 
point is that this dulness, to be indicative of adenopathy, must be 
permanent, found during several examinations. As has been pointed 
out by Grancher and J. E. H. Sawyer, 3 in debilitated and rachitic 
children there are observed transient areas of dulness, due to a bronchus 
being plugged with secretions and the resulting atelectasis of the air 
vesicles it supplies. 

Auscultation. — In my experience auscultation has been of more 
service in attempting to diagnosticate intrathoracic glands. Normally 
the breath sounds in children are louder and somewhat harsher than in 
adults — puerile. But this, in healthy children, is heard all over the 
chest. Swollen glands alter them in circumscribed areas. Thus, 
when large, we may find feeble breathing over a limited area, owing to 
compression of a bronchus, or to modifications in the pulmonary 
circulation in that region. On rare occasions the breath sounds are 
feeble over an entire lung anteriorly and posteriorly. But this is liable 
to great variations. I have followed some children for years and 
found that at times th^re are modifications in the breath sounds in a 
given area which shift so that at the next examination, one or more 
months later, the modification is found at another place. It may be 
found that during an attack of an intercurrent disease, rhinopharyn- 
gitis, influenza, etc.— when the glands swell up and there is an exacer- 
bation of the tuberculous process — the auscultatory phenomena make 
their appearance to disappear after the acute process 1 is gone. 

Anteriorly the auscultatory signs in children are uncertain, because 
normally we may hear the tracheal sound at the sides of the manu- 
brium in emaciated but non-tuberculous children with narrow chests. 
Still, when tubular breathing is heard unilaterally at the side of the 
sternum it speaks for enlarged glands. Posteriorly, bronchial or harsh 

1 Sixth Intern, Congr. on Tuberculosis, 1908, vi, 197. 

2 British Med. Jour., 1912, ii, 966. 3 Birmingham Med. Review, 1912, xix, 57. 



TUBERCULOSIS DURING EARLY CHILDHOOD 407 

breathing in the interscapular space of one side is an indication of the 
transmission of the tracheal murmur by enlarged glands which act as 
sound conductors. In mild cases only prolonged expiration is heard 
in one interscapular space, but in those in which the glands are very 
much enlarged, the breathing over a limited area may be tubular, or 
exquisitely bronchial; almost the same as is audible when listening 
directly over the trachea. 

D'Espine's Sign: Tracheophony. — About thirty years ago A. d'Espine 1 
described a sign of enlarged tracheal glands which appears to be more 
satisfactory than any other symptom or sign at our command at 
present. It consists in auscultation of the voice, especially the whis- 
pered voice, along the course of the trachea posteriorly. He described 
this sign as follows: The patient is told to count "one, two, three," 
or "thirty- three," as clearly as possible (younger children may be 
told to say "papa," "mamma") while the examiner auscultates with 
the naked ear, or better with a stethoscope, the spines of the cervical 
vertebrae. So long as we listen to the cervical spines, we hear the 
characteristic tracheal tone and each word is quite clear. In a 
normal child this clear voice stops abruptly as soon as we reach the 
seventh cervical spine where the lung begins; but in cases with bron- 
chial adenitis the clearness of the voice, or the tracheal tone, continues 
lower down, from the first to the fifth thoracic vertebra. It is at this 
spot that the main localization of the enlarged bronchial glands is 
found. The transmission of the tracheal tone in these cases is effected 
by the enlarged glands which surround the trachea at its bifurcation 
and often reach the spinal column, acting as sound conductors between 
the trachea and spine. 

When auscultation of the full voice gives uncertain results, the 
patient is told to whisper "thirty-three," which is even more reliable 
than the bronchophony just spoken of. It must always be borne in 
mind that in healthy children and adults, bronchophony and the 
whispered voice stop abruptly at the seventh cervical spine, and when 
heard lower it is a sure sign of something interposing between the 
trachea and the spine, and acting as a voice conductor. 

This sign of tracheobronchial adenopathy has been extensively 
tried in France and many report that it is more reliable than any 
other sign. Barot 2 found it superior to percussion and even more 
trustworthy than skiagraphy for the purpose of ascertaining the 
presence or absence of enlarged thoracic glands. In this country it 
has been strongly recommended by Stoll, Sewall, 3 Howell,- Honeij, 5 
and others. 

In evaluating this sign it must be borne in mind that the height 
of the bifurcation of the trachea, where the glands are most likely 

1 Traite des Malad. de l'enfance, Paris, 1900, p. 856. 

2 Arch, medicales d 'Angers, 1907, xii, 18. 

3 Jour. Am. Med. Assn.^ 1913, lx, 2027. 4 Am. Jour. Dis. Children, 1915, x, 90. 
5 Jour. Am. Med. Assn., 1913, lvii, 958. 



408 PULMONARY TUBERCULOSIS IN CHILDREN 

to become enlarged in tuberculosis, differs according to the age of the 
patient. In infants and young children it is on a level with the seventh 
cervical vertebra. But with advancing age it sinks lower and lower. 
At the age of eight it reaches the second or third thoracic vertebra, and 
at twelve it is found as low as the fourth. In adults, especially in 
senile individuals, it may be found as low as the fifth or sixth thoracic 
vertebra. Therefore, in a child of ten, the transmission of the whispered 
voice to the third thoracic vertebra may not mean enlarged glands in 
the chest. 

It must also be emphasized that the mere transmission of the vocal 
resonance as heard over normal lungs is not d'E spine's sign. This is 
found very often in children without enlarged glands. It is the trans- 
mission of the characteristic tracheal timbre which counts. In most 
cases it is heard not only along the spine, but also in the interscapular 
space on one side; at times bilaterally. 

I have tested this sign in various ways and found it most satisfac- 
tory. In several cases the skiagraphic plate failed to disclose the pres- 
ence of enlarged glands while d'Espine's sign revealed them. Armand 
Dellile, 1 Zabel, 2 and d'Espine mention cases which were verified by 
autopsy. 

Smith's Sign. — Eustace Smith's sign of bronchial adenopathy 
remains to be mentioned. It consists in this: If the child be made 
to bend back the head, so that the face becomes almost horizontal, 
and the eyes look straight upward at the ceiling above him, a venous 
hum, varying in intensity according to the size and position of the 
diseased glands, is heard with the stethoscope placed upon the upper 
bone of the sternum. As the chin is now slowly depressed, the hum 
becomes less loudly audible and ceases shortly before the head reaches 
its ordinary position. Smith explains this phenomenon in this fashion: 
While the head is bending backward, the lower end of the trachea is 
tilted forward, carrying with it the glands lying in its bifurcation, and 
the left innominate vein, as it passes behind the first bone of the 
sternum, is compressed between the enlarged glands and the bone. 

In my own experience this sign is not very reliable. It is found in 
short-necked children without enlarged glands, and is absent in many 
with adenopathy. Gibson 3 pointed out that it is mostly found in 
children who have enlarged veins in the neck and on the chest. 

Reflex Symptoms. — There are other symptoms of tracheobronchial 
adenopathy which are described in great detail in text-books, but 
which are, in fact, very rare and may be left out of consideration in the 
average case. Thus, pressure on the recurrent nerve may produce 
paralysis of the right vocal cord; pressure on the sympathetic may 
produce differences in the size of the pupils. Pressure on the vagus 
may produce tachycardia and palpitation, transient or permanent. 

1 Diagnostic et traitement de l'adenopathie tracheo-bronchique, Paris, 1911. 
2 Munchen. med. Wchnschr., 1912, lix, 2664. 
3 British Med. Jour., 1906, ii, 1051. 



TUBERCULOSIS DURING EARLY CHILDHOOD 409 

But these symptoms are very rare and are not conclusive even when 
encountered. 

In young children caseated glands may break through into adjoin- 
ing structures, the bronchi, trachea, esophagus, etc. More rarely 
yet, the swollen glands acquire such dimensions that by pressure on 
a bronchus they prevent the entry of air into the part of the lung 
supplied by this tube; or by pressure on the trachea fatal asphyxia is 
produced. But these cases are extremely rare and may be considered 
medical curiosities. 

Skiagraphy. — With the enthusiasm of the first years of radiography, 
we thought that with the aid of the .r-rays we had at last found a 
means for positively identifying enlarged tracheobronchial glands. 
Radiographers often made diagnoses of tuberculosis in children who 
showed no symptoms of active disease and continued well indefinitely. 

This was but natural, considering that normal glands allow the rays 
to pass through without casting any shadows, unless there is engorge- 
ment. Caseated glands cast a shadow which is occasionally distinct, 
but at times very indefinite. Only calcified glands cast a distinct 
shadow which may be identified in the vast majority of cases. But 
calcified glands, tuberculous in origin undoubtedly, are an indication 
that the disease has come to a standstill; in fact, this is the only mode 
of cure of caseated glands. 

Under the circumstances the most easily diagnosticated cases of 
tracheobronchial adenitis, when the .r-rays are used for the purpose, 
are those which have no significance clinically — those with calcified 
glands. When we attempt to clear up a case in which the glands are 
swollen, but neither caseated nor calcified — in other words, at a time 
when therapeutic measures may be inaugurated with a good chance 
of helping the patient — the .r-rays very frequently fail to give conclusive 
proofs of the existence of trouble. On the other hand, they show old 
and calcified glands which may not be, and often are not, the cause 
of the clinical symptoms for which the patient consults us at the time. 

Fluoroscopy is of no value at all in most cases of young children 
who cannot be managed in a totally dark room, asked to breathe 
deeply, cough, etc. The best is a skiagraphic plate, taken instanta- 
neously, and studied after it has been developed. But even here we 
must be careful before concluding that because there is a shadow at 
the hilus, there is active tuberculosis of the intrathoracic glands. In 
nearly all infectious diseases of childhood, but especially in scarlet fever, 
measles and whooping-cough, these glands are enlarged, but the 
swelling slowly retrogresses during convalescence. In fact, de Mussy 
attributed the paroxysms of cough in pertussis to enlarged glands. It 
is therefore hazardous to diagnose tuberculous adenitis in a child with 
whooping-cough, or scarlet fever, as I have seen done. 

Sluka 1 insists that several plates taken at long intervals are neces- 

MVien. klin. Wchnschr., 1913, xxvi, 254. 



410 • PULMONARY TUBERCULOSIS IN CHILDREN 

sary, so that evanescent enlargements of the glands may be excluded. 
In fact, he found that the shadows shown on the plate of the same 
child at irregular intervals have been larger at one time and smaller at 
another; at times involving almost a complete lobe, or even a whole 
lung, at other times only a small circumscribed shadow was found; at 
one time in the right side, at other times in the left, etc. A consider- 
able part of these changes is due to changes in the collateral inflam- 
mation in active cases, but it seems to me that differences in the 
technic of taking the picture, the distance of the tube from the patient's 
chest, the sharpness of the focus, the condition of the tube, etc., are 
responsible in many cases. 

The more extensive the experience of roentgenologists the less likely 
they are to diagnose tracheobronchial adenopathy, relying solely on 
.r-ray findings. Thus, I. Seth Hirsch says: "Markedly indurated and 
enlarged lymph nodes are visible as sharply defined, clearly differen- 
tiated round, ring-like, or partly triangular shadows occupying the 
position of the hilum shadow and extending out beyond this. But even 
this variety of lymph node disease may not be visible when affecting 
the paratracheal glands. When, however, these glands are the seat 
of calcareous degeneration, they are visible, whether tracheal or medias- 
tinal; but here also the mere presence of calcareous deposits at the 
hilum does not mean a calcareous nucleus in a tubercular lymph node, 
for they may be due to anthracosis, calcareous deposits in the vessels 
or the bronchial wall, the result of chronic, non-tuberculous interstitial 
inflammations." 

On the whole there is no doubt that shadows in the region of the hilus 
are indicative of enlargement or engorgement of the glands in that 
region. This mottling and stippling of the hilus is, however, no cri- 
terion as to the activity of the disease. Even the triangular or wedge- 
shaped shadow, with the base to the hilus, which has been described 
by Stoll and Heublein, Sluka, and others, is no proof of active disease, 
as the writer has repeatedly convinced himself. It appears also that 
in young infants these hilus shadows are only rarely seen even when 
adenopathy exists. Sluka says that in children under two years of 
age he never obtained a shadow on a chest plate which would even 
remotely suggest hilus tuberculosis, though he has taken numerous 
plates of sick children. He says that only during the third and fourth 
year do the glands begin to reveal themselves roentgenologically; they 
are mostly seen during the sixth and seventh years, and then begin to 
decrease in frequency. 

Of late the confidence formerly placed in .r-ray findings in intra- 
thoracic conditions has been waning. At the 1915 meeting of the 
American Pediatric Society, 1 Koplik said that "one should be very 
cautious in permitting an .r-ray to make a diagnosis for him." Holt 
stated that he had "sent the same case to a radiologist on successive 

1 Medical Record, 1915, lxxxviii, 502. 



TUBERCULOSIS DURING EARLY CHILDHOOD 411 

days and each day a different diagnosis was made. The .r-ray is very 
misleading and a dubious procedure upon which to base a diagnosis." 

In doubtful cases the skiagraphic plate may gire some indefinite infor- 
mation about the presence of enlarged thoracic glands. But when found 
in a child showing no clinical symptoms of the disease, we must not 
conclude that the child is actively tuberculous. We do not as yet have 
enough experience with skiagraphy in healthy children, nor have 
enough autopsies been made to verify skiagraphic findings, to warrant 
unequivocal conclusions. 

Tuberculin Diagnosis. — Basing their opinion on the fact that tuber- 
culosis in infants is almost invariably fatal, it has been concluded that 
when in a young child any of the tuberculin tests is positive, and there 
are some symptoms, such as cough, etc., the child should be pronounced 
tuberculous to the great dismay of the parents. I have seen children 
kept from school and thus deprived of an education, and perhaps 
hampered for the rest of their lives, solely because the von Pirquet 
reaction was found positive. 

We have already shown that the tuberculin reaction shows but one 
thing — whether the person — child or adult immaterial — has ever been 
infected with tubercle bacilli. But it does not show conclusively 
whether the infection was followed by disease. Inactive infection is 
more likely to give a strong reaction than active tuberculous disease. 
In fact, in fatal tuberculous bronchopneumonia, meningitis, etc., the 
reaction is negative; in others it is but faintly positive. In other 
words, the stronger the reaction, the less likelihood of active or dan- 
gerous disease in the child, and a negative reaction is no positive 
proof of the absence of dangerous tuberculous disease. 

In infants under two years of age a positive reaction is to be taken 
as an indication of active disease because at that age infection is very 
likely to be followed by disease; during the first six months of life, 
almost invariably. But after two years of age harmless infections 
are the rule, so that the value of the tuberculin reaction acquires an 
academic importance, as was already shown, but it loses its clinical 
value. This is a point which pediatrists should bear in mind. It should 
never be lost sight of that after the third year latent tuberculosis is 
very common and this gives the same reaction as active disease. 

Diagnosis. — The diagnosis of tuberculous tracheobronchial aden- 
opathy depends on the presence or absence of clinical symptoms of 
disease. A child over two years of age showing a three plus tuberculin 
reaction, and a shadow in the region of the hilus on the skiagraphic 
plate is to be considered well and healthy so long as it presents no 
symptoms of disease; so long as there is no fever, no cough, no ema- 
ciation, etc. It is different with those who have clinical symptoms. 
In these it is always important to remember that when a child does 
not thrive, fails to gain in weight, the cause must be found. If it is not 
found, and there is cough, especially that dry, brassy cough, the tem- 
perature is to be taken three or four times a day. If it is found that 



412 PULMONARY TUBERCULOSIS IN CHILDREN 

there is an irregular fever, of the type described above, there is pre- 
sumption of tuberculosis. If on examining the chest we find some 
dulness in one of the interscapular spaces, or anteriorly in the upper 
two interspaces near the sternum; and the whispered voice and the 
tracheal tone along the spine, and in one or both interscapular spaces 
are audible in the peculiar characteristic fashion described when 
speaking of d'Espine's sign, the diagnosis of tracheobronchial aden- 
opathy is clinched. 

It is different when these signs are found, even in conjunction with 
skiagraphic findings and a positive tuberculin reaction, in a child 
which shows no clinical symptoms of disease. There is no doubt that 
this child may also have, and probably does have, enlarged bronchial 
glands. But these glands are not actively diseased, and so long as the 
little patient thrives, there is no cause for alarm. The glands are of no 
more clinical value than the scars found in the apices of 90 per cent. 
of adults who die from causes other than tuberculosis; they are of no 
more serious import than the enlarged glands found on the necks of over 
50 per cent, of evidently healthy children in the slums of large cities. 

Prognosis. — The prognosis of tuberculosis in children under ten 
years of age embraces two problems: (1) The immediate outlook; 
and (2) the ultimate outlook. In other words, what are the chances 
of survival, or of retaining good health, immediately after infection 
has taken place, and is the child destined to develop phthisis after 
reaching the age of adolescence? 

The immediate outlook appears to be good, provided the lesions 
remain localized in the glands, or even in the bones and joints. This 
is clearly seen in cases of superficial glandular tuberculosis: Most 
children with tuberculous cervical adenitis, especially those requiring 
no operative interference, recover after a protracted illness. The 
same is true of osseous and articular tuberculosis. From 900 cases of 
tuberculous disease of the hip treated by A. Bowlby 1 at the Alexandra 
Hospital in London during twenty-one years, 33 died — a mortality of 
4 per cent. He found that of the 33 who died, 24 were attacked by the 
disease before the age of six. The mortality from tuberculous tracheo- 
bronchial adenitis is undoubtedly even lower. The greatest danger is 
metastasis in the meninges, but even this is comparatively infrequent 
after the fifth year. 

For this reason all methods of treatment of tuberculosis in children 
produce most excellent results. This is also the reason why orphan 
asylums — which harbor children between four and fourteen years of 
age — report that, despite the fact that most of their inmates are 
derived from the poorest strata of population, and an enormous pro- 
portion are of tuberculous stock, they have no morbidity nor mor- 
tality from tuberculosis. It is simply because death from tuberculous 
tracheobronchial adenopathy is extremely rare. The success of the 

1 British Med. Jour., 1908, i, 1465. 



TUBERCULOSIS DURIXG EARLY CHILDHOOD 413 

open-air schools, the preventoriums, etc., should also be attributed 
in a great measure to this cause. 

Barring meningeal complications or intercurrent acute infectious 
diseases, the prognosis in tracheobronchial adenopathy is excellent. 

In older children, seven years of age or more, the prognosis of 
apical pulmonary tuberculosis of the same type as seen in adults is 
more serious, though not so serious as in adults. It appears that 
pulmonary lesions in children heal with greater ease than in adults, 
though now and then we meet with a case in which the process in the 
lung proceeds to cavitation and the child succumbs to the usual clinical 
manifestation of phthisis. After the twelfth year there is hardly any 
difference in the clinical pictuie and prognosis of phthisis in children 
and in adults. 

Says Franz Hamburger, 1 one of the most experienced men in this 
field : rt In general we can lay down the fundamental principle that the 
prognosis of tuberculous manifestations in children is not at all bad. 
It is, in fact, one of the most important achievements of recent years 
that we know: 'tuberculosis in children is a relatively harmless 
disease.' It will naturally take decades till the lay public will learn 
this important fact." And I may add till physicians in general will 
learn it. 

The prognosis also depends on several other factors: The younger 
the child showing active tuberculous manifestations, the worse the 
outlook, the more liable it is to suffer from, or to succumb, to metas- 
tatic tuberculous manifestations, such as meningitis, rupture of a 
gland into a bronchus, the trachea, or esophagus. These complications 
in fact become less frequent after the third year of life, and after the 
sixth year they are comparatively rare. The prognosis also depends 
on various accidental complications. Thus, a child that escapes the 
endemic diseases, such as measles, whooping-cough, scarlet fever, 
diphtheria, etc., may grow up into healthy manhood, in spite of the 
enlarged glands in the chest which disappear in nearly all cases after 
the tenth year; at any rate they give no more trouble. It is thus clear 
that the prognosis also depends on the social and economic conditions 
under which the child is raised. Those who are well off in this regard 
survive unscathed, because they have good nourishment, healthy 
dwellings, frequent vacations and are less likely to contract other 
diseases, etc. 

The second element in the prognosis of tuberculosis during child- 
hood is the problem whether every child infected at an early age is 
destined to become phthisical after the fifteenth year of life. The 
facts observed in daily practice seem to be against such a view. If 
this were the case tuberculosis among adults would not kill only one 
out of seven to ten individuals, as is now found wherever there are 
available vital statistics, but over 90 per cent, of humanity would 

1 In Brauer. Schroder, ard Blumeofeld, Handbuch der Tuberkulose. 1915. v, 31, 



414 PULMONARY TUBERCULOSIS IN CHILDREN 

succumb to phthisis. That an active tuberculous lesion during child- 
hood is not necessarily followed by phthisis in later life is evident from 
the following facts: 

We meet with many persons showing unmistakable signs of having 
had some form of tuberculosis during childhood, but pass through 
life as healthy and even vigorous individuals. This is the case with 
those showing scars on the neck which are undoubtedly remnants of 
tuberculous adenitis which had suppurated or were operated upon. 
We meet with many showing remnants of articular and osseous tuber- 
culous disease, yet they pass through life without developing phthisis. 
In fact, the contrary seems to be true. Those who see large numbers of 
phthisical patients are struck by the fact that consumptives with 
scars on the neck, or with ankylosis of joints following earlier tuber- 
culosis, etc., are extremely rare. In a statistical study of 2000 cases 
of clinical tuberculosis Stanley L. Wang 1 found only 20 patients show- 
ing old cervical scars due to tuberculous disease which had occurred 
in childhood. He also found that tuberculous patients having these 
scars generally show a greater tendency to improve with the usual 
sanatorium care than others. This has also been observed to be a fact 
by many other clinicians, as has already been discussed (see p. 125), 
and seems to indicate that an ea^ly tuberculous lesion may have some 
immunizing effect on the organism and prevent the development of 
phthisis in later life. 

We are, at the present state of our knowledge, not warranted in 
asserting that this protection against phthisis conferred by a early 
tuberculous disease depends on infection with bovine tubercle bacilli, 
as some have been inclined to assume. But we may safely draw a 
conclusion that an early tuberculous disease of the tracheobronchial 
glands is not necessarily followed by phthisis in later life, and there 
seems to be evidence that it may act in the same manner as articular, 
osseous, and other glandular tuberculosis. 

1 Jour. Am. Med. Assn., 1917, lxviii, 1963. 



CHAPTER XXV. 
PHTHISIS IN THE AGED. 

Frequency. — 'While discussing the frequency of tuberculosis during 
the various age periods we have shown that no age is exempt; in fact, 
it appears from available mortality statistics that after the age of 
twenty the death-rates from phthisis are about the same till very 
advanced life. ^Yhile making autopsies pathologists are often struck 
with the frequency with which active tuberculous lesions are found in 
the lungs of aged persons, and investigations in homes for the aged show 
clearly that a large proportion suffer from phthisis. Thus, E. Braun 1 
while making autopsies noted that in all bodies of persons over sixty 
years of age miliary tuberculosis was detected. The lungs were nearly 
always affected. In many the spleen, kidneys, and liver were involved ; 
the meninges in only 10 per cent, of cases. 

The reason why popular opinion has ascribed immunity of old 
subjects to phthisis appears to lie in the fact that, when occurring, 
this disease runs a mild benign course and may pass off as bronchitis, 
asthma, etc. But when the sputum expectorated by senile persons is 
examined, it is very frequently found to contain large numbers of 
tubercle bacilli. In fact, these aged consumptives may be considered 
actual bacillus "carriers" who, without themselves suffering very 
much from the bacilli, disseminate the disease much more widely 
than younger patients who know of their condition and the danger 
of indiscriminate expectoration. 

Etiology. — Most phthisis in the aged has been acquired during 
childhood, but has been held in abeyance throughout life, to break out 
again at the period of life when the organs of the body begin to suffer 
as a result of wear and tear. Others have suffered from some form of 
phthisis before, but the disease was "cured," to reawaken during old 
age. Many have been afflicted for years with some form of fibroid 
phthisis, but when senile degeneration began to manifest itself the 
tuberculofibroid lesions in the lungs began to activate with more vigor. 

From our present knowledge of phthisiogenesis we must exclude 
new infections of aged persons, because they have been infected during 
the earlier years of life, as was already discussed elsewhere. A new, 
or primary, infection in an adult would surely not pursue such a slow, 
sluggish course as is seen in the aged. The active disease in senile 
individuals should be considered either metastatic, or else old, perhaps 
dormant, processes flaring up and causing disease. 

i Coit,-B1. f, Schwelz. Aerzte, 1917, xlvii, 1121. 



416 PHTHISIS IN THE AGED 

Pathologically, there are no differences in the lesions between the 
aged and those in adults in general, with but few exceptions. In the 
aged the fibroid processes predominate because the tendency to fibrosis 
of tissues is characteristic of advancing age. These fibroid formations 
tend to limit the lesion, prevent its spread and to surround the cavities, 
which show no tendency to enlarge by contiguity of the process. On 
the other hand, bronchiectatic cavities are more frequently found in 
old than in young consumptives. 

Symptoms. — "The conditions with which it may be associated 
modify the course of the tuberculous process," says J. Edward Squires, 1 
" so that the symptoms are obscured, and the signs of its presence in 
the lung are somewhat indistinct. Tuberculosis, when it attacks lungs 
already damaged by the degeneration of age, may add but little to 
the discomforts of the individual who is already short of breath and 
'wheezy.' The increasing infirmity of the patient is accepted as a 
sign that he is aging more rapidly, and no suspicion of any added mis- 
chief is aroused or entertained." Generally speaking, the symptoms of 
phthisis in the aged are often those of fibroid phthisis, which have 
already been described. From most patients who consult us for hem- 
optysis, cough, expectoration, and a lesion is discovered on physical 
examination, we elicit a history that they have been troubled with 
some of these symptoms for years, perhaps since childhood, but that 
they have been considered as suffering from chronic bronchitis or 
pulmonary emphysema. 

The patients cough, but the cough is mild. In aged persons the 
stimulus for cough is not so intense as in the young because the sensi- 
bility of the bronchial mucous membrane is greatly diminished. The 
quantity of sputum they expectorate is, as a rule, not very consider- 
able because they have a tendency to swallow it. When told that 
they are tuberculous they are apt to resent the imputation, claiming 
that they have coughed for years, perhaps since they can recall, and 
if it had been "consumption" they would have succumbed long ago. 

Most senile patients are of slim build, but occasionally we meet with 
a tuberculous patient over sixty who is above the average weight. 
But with the onset of active symptoms they begin to lose in weight, 
and within a few months they may be reduced to mere skeletons. 

A large proportion of patients have no fever, though the methodical 
use of the thermometer per rectum may reveal a typical tuberculous 
temperature with slight rises, to 101° F. in the afternoon. In this 
respect phthisis does not differ from other diseases in the aged. We 
know that pneumonia may pass an afebrile course in the senile. The 
organism of the aged does not react with fever as does the body of 
the young. 

The pulse is more rapid than normal for the age of the patient. In 
rare cases tachycardia is seen, especially when there is cardiac dis- 

1 International Clinics, Sixteenth Series, 1906, iv, 90. 



PHYSICAL SIGNS 417 

placement. Dyspnea is a frequent symptom, especially after exertion. 
Because of the concomitant arteriosclerosis and myocarditis, cyanosis 
is not uncommon. In the later stages, when heart failure is apt to 
occur, edema of the extremities is frequently seen. The blood-pressure 
is low considering the age and the condition of the arteries of the 
patient. Hemoptysis occurs quite frequently. In most cases it is 
merely streaky sputum, but it may be profuse and I have seen a fatal 
hemorrhage in a woman, aged seventy-eight years. Nightsweats are 
rare because, with advancing age, the sweat glands undergo atrophy, 
and also because the great oscillations of temperature characteristic 
of phthisis in the young are absent in the senile. 

A large proportion of aged tuberculous persons suffer from persistent 
diarrhea. In some it is very difficult to control by dietetic or medicinal 
treatment. Moreover, when the diarrhea is the dominant symptom, 
the symptoms and signs in the chest are overlooked, and a diagnosis 
of a gastro-intestinal disturbance is made. It is advisable that in all 
cases of persistent diarrhea in senile patients the chest should be care- 
fully examined, and inquiry made about the constitutional symptoms 
of phthisis. 

Physical Signs. — The appearance of the senile phthisical chest 
depends on the character of the lesions in the lungs. In those in whom 
there is pulmonary emphyse^na in addition to the tuberculous process 
there is the characteristic barrel-shaped chest, rigid, hardly expanding; 
in fact, always in the position of maximum inspiration. All that is 
seen is that the entire chest is lifted up with each inspiration, but there 
is no anteroposterior or lateral expansion. The intercostal spaces are 
wide and the direction of the ribs is more horizontal than normal. 
But many have no old emphysema and in them the thorax is rigid 
owing to the ossification of the costal cartilages; the ribs run at a 
more acute angle to the spine than normal and the intercostal spaces 
are wider; the supraclavicular and infraclavicular spaces are deeply 
excavated, more so on one side. During fits of coughing either apex, 
or both, may be seen blowing up in the supraclavicular space. Dilata- 
tion of the veins of the neck is a frequent symptom, and when there is 
relative tricuspid insufficiency, owing to dilatation of the right heart, 
there may be a venous pulse. Kyphosis and kyphoscoliosis are never 
absent. 

Auscultation is also not so satisfactory as in young subjects. The 
breathing is superficial and, combined with pulmonary emphysema, 
which is only rarely absent, we may hardly hear any breath sounds, 
or only a feeble murmur is audible. These are also the reasons why 
bronchial or cavernous breathing is so rarely heard over the sites 
of cavities. Broncho vesicular breathing of low pitch, with prolonged 
expiration may, however, be made out over one apex, at times, while 
carefully auscultating the chest. Rales are not audible in many cases 
because of the superficial breathing; but over the sites of excavations 
large, consonating rales may be heard, even when no breath sounds 
27 



418 PHTHISIS IN THE AGED 

are made out. At the base, these rales are usually due to bronchitis or 
bronchiectasis which are very frequent in old age. 

Course.- — In many cases the cough, expectoration, emaciation, 
etc., continue for years and, inasmuch as these old persons do not 
follow occupations necessitating physical exertion, the true nature 
of the disease is not even suspected. They are considered patients 
suffering from chronic bronchitis or emphysema. I know old con- 
sumptives who have survived children and grandchildren whom they 
infected with tuberculosis. In fact, whenever I discover children with 
signs of tuberculous infection, though a history of exposure cannot 
be made out, I inquire for the grandparents, and have, on many 
occasions, found that one of them was the source of infection, though 
he did not know the true nature of his illness. 

In the vast majority of cases the tendency of the disease is to pro- 
gress, though slowly, and never to a cure. Occasionally we find that 
it advances rapidly, assuming an acute or subacute course, with hectic 
fever, rapid emaciation, etc. Owing to the weakness and the general 
debility the cough is usually not at all severe, and when there is no 
fever, a diagnosis of carcinomatosis is made. Others cough and expec- 
torate for years, when suddenly fever develops and the patient is 
carried off within a few days. Bronchopneumonia may have been 
erroneously considered the cause of death, unless the sputum was 
examined and tubercle bacilli were found; a diagnosis of acute pri- 
mary tuberculosis may then be erroneously made. Daremberg speaks 
of acute phthisis in the aged, and Hoppe-Seyler speaks of acute miliary 
tuberculosis on rare occasions. But these cases are evidently acute 
exacerbations of chronic phthisis which had been kept in abeyance for 
years. The large proportion of cases of acute miliary tuberculosis 
found by Braun while making autopsies on aged persons show that it 
is frequently overlooked by clinicians. He points out that paradoxical 
bronchitis and bronchopneumonia, with signs of heart failure, doubt- 
less usually conceal the presence of acute miliary tuberculosis in the 
aged. 

Diagnosis. — The diagnosis is not difficult when the possibility of 
phthisis is kept in mind in all cases of cough, expectoration, emacia- 
tion, etc., met with in senile patients. Most of the mistakes made in 
these cases are due to failure to examine the sputum for tubercle 
bacilli. When the physical signs in the chest are indefinite, which is 
often the case, the bacteriological findings decide. "When looking for 
fever in these cases we should never rely on the axillary temperature; 
only the rectal is to be taken. 

We must guard against mistaking signs of old, healed lesions for 
active disease. This can be avoided by a careful study of the symp- 
tomatology and bacteriology of the affection. 



CHAPTER XXVI. 
TUBERCULOSIS OF THE PLEURA. 

The serous membranes of the body, the meninges, the peritoneum, 
the pericardium, and the serous linings of the joints, are very much 
predisposed to tuberculous disease. As a serous membrane, the pleura 
is no exception in this respect. Indeed, it may be stated that tuber- 
culosis of the pleura is at least as common as tuberculosis of the lungs. 
In all forms of phthisis the morbid process extends from the pulmonary 
parenchyma to the visceral pleura. Its anatomical relations, blood 
supply, and lymphatics, render the pleura peculiarly liable to infection 
with tubercle bacilli which, as we have already shown, spread within 
the body either hematogenically or lymphogenically. Of the two 
sheets, the visceral, especially the parts covering the pericardium and 
diaphragm, is very thin and firmly adherent, while the parts covering 
the surface of the lungs are thinnest and detached only with difficulty. 
The costal pleura is thicker and covered with flattened epithelial cells, 
while the cells covering the visceral pleura are less distinctly flattened, 
more granular and polyhedral. The pleura rests on a thin layer of 
subserous areolar tissue containing numerous elastic fibers. These 
areolar and elastic fibers are continuous with the elastic fibers and 
connective tissue within the lungs. 

The blood supply of the pleura is not an independent system, but is 
derived from two sources : The visceral pleura is, through its circula- 
tion, intimately connected with the lung, being supplied with branches 
of the pulmonary and bronchial arteries, but the capillaries beneath 
the visceral pleura form a coarser network than those of the pulmonary 
alveoli. On the other hand, the parietal pleura is supplied from the 
intercostal, phrenic, internal mammary, mediastinal and bronchial 
arteries. It is thus clear that disturbances in the bronchial and alveolar 
circulation may affect the pleura, especially the visceral sheet. More- 
over, inflammatory conditions of the lungs, when extending to the sur- 
face, will almost invariably implicate the visceral pleura, while the 
parietal sheet will only be affected through contact. 

The visceral pleura is very rich in lymphatic vessels and glands which 
are often visible to the naked eye. They are scattered all over the 
surface of the pleura, but are most numerous on the membrane cover- 
ing the interlobar fissures. Their connection with the bronchial glands 
is evidenced by the fact that they too become darker in older individuals 
owing to the deposition of carbon particles brought into the lungs with 
the inhaled air. The lymphatics of the parietal pleura pass to small 



420 TUBERCULOSIS OF THE PLEURA 

intercostal glands situated near the heads of the ribs, and indirectly, 
through their connection with the lymphatics of the fourth and fifth 
intercostal spaces, with the axillary glands. There are also communi- 
cations between the lymphatic systems of the chest and the abdomen 
through anastomosis between the lymph vessels of the pleura and those 
of the peritoneum, particularly that covering the lower surface of the 
diaphragm. At first sight a closed cavity, the pleura is thus seen to 
communicate through its bloodvessels and lymphatics, in the latter by 
means of stomata, with the air inhaled into the lungs, as well as with the 
abdomen. Infection of any part of the lungs or its glands, or of the 
peritoneum, is likely to spread hematogenically or lymphogenically to 
the pleura. In fact, experimental investigations of Grawitz, Grober, 
Fleiner, and others, have shown conclusively that coloring matter 
insufflated into the lungs of animals was subsequently found in the 
pleura. Tubercle bacilli carried by the blood, or especially the lymph 
stream, may thus produce pleurisy even if the lungs remain unaffected. 
Primary tuberculous pleurisy is thus explained. 

Pathology. — While making autopsies on tuberculous bodies we almost 
invariably find that the pleural sheets, in part, or even completely, are 
covered with fibrinous exudate, a false membrane ; are adherent at some 
circumscribed area, or more extensively, and thickened. 

An exudate in which fibrin filaments are more or less abundant is 
frequently found within the pleural cavity. In nearly all cases of 
chronic phthisis the pleural sheets over the affected upper lobe are 
thick, and densely adherent, so that the lung cannot be removed 
without force; either the parenchyma, or the tissues on the inner side 
of the chest wall, must be forcibly torn or cut for the purpose. Next in 
frequency, thickening and adhesions of the interlobar and diaphrag- 
matic pleurae are found. The interlobar fissure near the affected part 
is thus often obliterated. In acute cases miliary tubercles may be 
found scattered all over the surface of the pleura; in others tuberculous 
neoformations occur; they may form large villous tumors which, in 
rare instances, are found pedunculated as in bovine tuberculosis of 
the pleura. Very often calcified areas are made out in the affected 
part of the pleura which, at times, may be over one centimeter in thick- 
ness, and converted into a fibrous or even calcified mass which sur- 
rounds the diseased and excavated part of the lung like a solid shell. 

Microscopically the false membrane in mild cases is made up of fibrin 
enmeshing red blood corpuscles and round cells. The pleura proper is 
invaded by young connective-tissue cells, tuberculous granulations, 
epithelioid and giant cells, and areas of caseation. The adjacent paren- 
chyma of the lung usually shows atelectasis of the alveoli, vascular 
dilatation, and proliferation of the epithelial cells. 

In a certain sense, the implication of the pleura in pulmonary tuber- 
culosis may be regarded as a protective process. The acute symptoms 
of pleurisy, especially the pain in the chest, impede the motion of the 
affected part of the thorax and thus afford rest to the diseased lung, 



PATHOLOGY 



421 



favoring cicatrization of the lesion. But this is of less significance when 
compared with the protection pleural adhesions afford the patient 
against loss of continuity of the visceral pleura resulting in pneumo- 





Fig. 74. — Tuberculous pleural adhesions. At the lower part of the drawing is to be 
noted that the subcostal cellular tissue is very much reduced in quantity. Above it 
the new membrane is developed at the expense of the visceral pleura and shows a layer 
of tuberculous follicles. The fibrous tissue gradually extending upward and coming in 
contact with the lung without any sharp line of demarcation between them, is already 
old, well organized in parallel bundles and passed by numerous bloodvessels. (Chante- 
messe and Courcoux.) 



thorax. When the tuberculous process reaches the cortical surface of 
the lungs, which it does in nearly all active and progressive cases, a 
minute caseated area will permit the entry of air into the pleura and 



422 TUBERCULOSIS OF THE PLEURA 

cause collapse of the lung. The pleural adhesions over the site of the 
lung lesion prevent this accident in over 95 per cent, of cases of phthisis. 
Varieties of Tuberculous Pleurisy.— The following forms of tuber- 
culous pleurisy may be differentiated clinically and pathologically: 

1 . Primary tuberculosis of the pleura, which is rare. 

2. Pleurisy during the course of acute pulmonary tuberculosis. Met 
with in nearly all cases. 

3. Pleurisy during the course of chronic pulmonary tuberculosis, 
encountered in various degrees of intensity and extent in nearly all 
cases of chronic phthisis. 

Each of these forms of 'pleurisy may be dry or moist. The latter 
class may have serous, serofibrinous, sanguineous, or purulent effu- 
sions. It may be unilatereal or bilateral; may involve the entire 
surface of the affected pleura, or only a limited area. 

PRIMARY TUBERCULOSIS OF THE PLEURA. 

Primary tuberculosis of the pleura is rare, if it occurs at all. It is 
clear that in such cases the virus must be brought to the pleura through 
the blood or lymph stream. Experimental investigation has shown 
that even when the pleura is directly inoculated in a healthy animal 
no local tuberculous lesion is produced. Cleveland Floyd 1 found that 
only when the pleura is sensitized by a previous infection for some days 
the response to infection with pyogenic microorganisms was in the 
nature of purulent effusion. Similarly, Robert C. Paterson 2 found that 
fluid is never produced by a primary inoculation of the pleura with 
tubercle bacilli. But in tuberculous animals inoculation of tubercle 
bacilli produces an exudate of serum, leukocytes, red blood corpuscles, 
and fibrin. He therefore arrives at the conclusion that clinical pleural 
effusions are caused by infection of an " allergic" pleura; in other words, 
that they are due to reinfections from within, or from without the body. 
This is confirmed by the clinical observation that pleural effusions are 
almost invariably preceded by many months, or years, by tuberculosis 
of some other organ in the body, notably the lung, the lesion remaining 
dormant. Pathologically also there are confirmations — in nearly all 
cases of tuberculous pleurisy that come to autopsy older lesions are 
found in the lungs, or the intrathoracic glands. 

Tuberculous pleurisy is found more frequently in men than in 
women. While no age is exempt, it is mostly found in adults. 
Pleurisy in children, with or without effusion, is, as a rule, non- 
tuberculous. Many patients give a history of exposure to cold as 
the immediate exciting cause. When we bear in mind that it is an 
endogenic reinfection with tubercle bacilli, we can readily conceive that 
exposure to cold may prepare a suitable soil for the tubercle bacilli 
brought there by the blood, or by contiguity to adjacent diseased 

1 Tr. Am.Climatol. Assn., 1914, xxx, 205. 

2 Am. Rev. Tuberc, 1917, i, 353. 



PRIMARY TUBERCULOSIS OF THE PLEURA 423 

organs. The blood and lymph supply of the parietal pleura, being 
derived from that of the chest wall (see p. 419) will predispose it to 
inflammation after chilling of the chest wall. It may be stated, how- 
ever, that the vast majority of these cases of "idiopathic" pleurisy are 
tuberculous. Autopsies made on persons with dry pleurisy, apparently 
due to "colds," have shown distinct tuberculous lesions of the lung and 
pleura. At times an injury is responsible for the onset of pleurisy. 
But it appears that individuals who do not harbor tubercle bacilli; or 
are otherwise not predisposed to tuberculosis, do not develop tuber- 
culosis of the pleura after an injury to the chest. During the recent 
World War tuberculosis of the pleura has been noted to follow injuries 
and wounds of the pleura only in exceedingly rare instances. 

Symptoms of Dry Pleurisy. — In general practice dry pleurisy is 
very frequently observed. After exposure, or without any known 
provocative cause, the patient is seized with some chilly sensations, 
though the acute chill characteristic of pneumonia is very rare, becomes 
feverish, has pain in the side of the chest, and more or less dyspnea. 
Unproductive cough is almost invariably present and it aggravates 
the dyspnea and the pain. In some instances paroxysmal attacks of 
cough occur which are very painful. Physical examination of the chest 
shows diminution of mobility, at times almost complete immobility, 
of the affected side of the chest. Percussion yields negative results, 
but auscultation reveals a dry friction sound, most commonly in the 
region where the pain is acutely felt — the lower part of the chest in the 
anterior axillary line, or the mammary region, or behind, in the region 
of the angle of the scapula. In some cases the pain is mild, but in others 
it is severe, lancinating. It may be relieved, more or less, by anything 
which tends to immobilize the affected side of the chest, and is aggra- 
vated by deep breathing or coughing. 

As has been pointed out by Capps, the pain in pleurisy is only felt 
superficially; it is "referred," and can be elicited only in the skin, sub- 
cutaneous tissue, and muscles. The sensitized area is hyperesthetic, 
hyperalgesia and often characterized by painful tender points. The 
muscular cutaneous reflexes are exaggerated, and can best be elicited 
by striking or pinching the skin. In most cases it is felt in the region 
of the affected pleura, i. e., where the friction sound is heard; tender- 
ness of the intercostal spaces may be elicited. 

In diaphragmatic pleurisy no friction sounds are heard on auscultation 
and the diagnosis is made mainly by a consideration of the general and 
local symptoms. The fever is, in most cases, high and the dyspnea 
severe owing to the immobility of the affected half of the diaphragm, 
the result of the pain which may be agonizing. The diaphragm derives 
its sensory nerve supply from two sources — the phrenic and the last 
six intercostal nerves. The central portion of the diaphragmatic pleura 
is innervated by the phrenic nerve. For this reason inflammation of the 
central portion sets up pain in the neck, at the crest of the shoulder, 
corresponding to the cutaneous distribution of the fourth cervical 



424 



TUBERCULOSIS OF THE PLEURA 



nerve, which has its center in the spinal cord at the same level as the 
phrenic. The periphery of the diaphragmatic pleura is innervated by 
the sensory fibers of the intercostal nerves and inflammation of that 
area gives rise to referred pain in the lower thorax, the lumbar region, 
or the abdomen. These points of tenderness in pleurisy have first been 
studied by Gueneau de Mussy, 1 who described boutons diaphragmatiques, 
points of maximum tenderness at the intersection of the parasternal 
line and a horizontal line continuous with the end of the tenth rib. 
More recently Sir John Mackenzie, 2 and especially Joseph A. Capps, 3 
have carefully studied the subject. 




Fig. 75. — Points of maximum pain and tenderness in abdomen and back occurring in 
61 cases of diaphragmatic pleurisy. (Capps.) 



In many cases of diaphragmatic pleurisy the referred pain over the 
abdomen and back (Figs. 75 and 76) is not unlike that due to appendicitis, 
gastric ulcer, cholelithiasis, and other intra-abdominal diseases. Capps 
mentions cases in which such errors have been committed; Lewis 
Sayre Mace reports several in which gastric ulcer was diagnosticated, 
and I have seen several cases of this type, especially in tuberculous 
patients who have recurrent attacks of diaphragmatic pleurisy and 
resulting adhesions. 

T. H. Kelly and H. B. Weiss 4 report a series of cases of diaphragmatic 
pleurisy which simulated surgical conditions so closely that the ques- 
tion of operative intervention was seriously considered. Among the 

1 Arch. gen. de med., 1853, ii, 271 ; 1879, ii, 141. 

2 Symptoms and Their Interpretation, London, 1910. 

3 Arch. Int. Med., 1911, viii, 717; Am. Jour. Med. Sc, 1916, cli, 333. 
* Am. Jour. Med. Sc., 1918, clvi, 808. 



PRIMARY TUBERCULOSIS OF THE PLEURA 



425 



diseases which required differentiation were renal stone, acute chole- 
cystitis, generalized acute peritonitis from perforated typhoid ulcer, 
etc. Some had in fact been operated upon for appendicitis and gall- 
bladder disease previous to coming under Dr. Kelly's observation. 
In none of those operated cases was stone or any other pathological 
condition of the intra-abdominal viscera found at the operation, and 
shortly afterward there was a recurrence of the symptoms that had 
existed before the operation. 




Fig. 76. — Points of maximum pain and tenderness in the neck region occurring in 
sixty-one cases of diaphragmatic pleurisy. (Capps.) 

Several cases of diaphragmatic pleurisy have come under my obser- 
vation in which the diagnosis was made of chronic recurrent appendi- 
citis, and operated upon ; others in which operation was performed for 
gastric ulcer because of hemorrhages which in reality were due to 
tuberculous lesions in the lung, or bronchiectasis which is not uncom- 
mon in chronic diaphragmatic pleurisy. One patient with a thick 
pleura over the right base was operated upon four times : For appendi- 
citis, for gall-stones, for gastric ulcer, and finally for "adhesions." 
He still has pain in the right side of the abdomen, and a surgeon urges 
another operation. We have already shown that hematemesis is at 
times difficult of differentiation from pulmonary hemorrhage (see p. 218) . 
In tuberculous patients, symptoms of appendicitis, especially of the 
chronic and recurrent type, should be carefully analyzed before a final 
opinion is given. 

The differentiation may be attempted along the following lines : In 
diaphragmatic pleurisy there are two areas of tenderness on pressure: 



426 TUBERCULOSIS OF THE PLEURA 

One posteriorly along the twelfth rib of the affected side; the second 
at the ridge of the trapezius. Spontaneous pain at these points may 
occur, but pressure elicits it in nearly every case. In some instances 
there is observed rigidity of the abdominal muscles of the affected side. 
But when this pain and rigidity of- the muscles are due to intra- 
abdominal disease deep pressure will produce severe and deep-seated 
pain; while when the pain over the abdomen is "referred," due to 
diaphragmatic pleurisy, deep pressure with the flat surface of the 
fingers is well borne, only cutaneous hyperalgesia is present; and pinch- 
ing the skin, or slightly stroking it, will elicit tenderness and pain. In 
chronic cases careful physical exploration of the chest will show, in 
most instances, signs of a thick pleura. 

Interlobar dry pleurisy of a tuberculous nature also occurs at times. 
No frictions are audible, as a rule, but feeble breath sounds are found 
while listening over the lung above the second or third rib, owing to 
immobilization of the lung above the affected part of the pleura. This 
•form of pleurisy is apt to recur, as has been shown by Piery, and after 
several attacks the lung is implicated in the tuberculous process. 
These cases of recurring interlobar pleurisy, as well as apical pleurisy 
which will soon be described, are characterized by symptoms of 
incipient phthisis without the pathognomonic physical signs and with 
negative sputum. If after several attacks the parenchyma is not 
implicated, the after-effects may be disagreeable, particularly when 
the lesion is in the left side of the chest. The thick pleura and the 
adhesions remain permanently and the cicatrix may contract. By 
their attachment to the mediastinum they may pull the heart out of 
its normal location outward and upward and thus hamper its action. 
I have seen cases of this type in which no signs of excavation, or even of 
infiltration, of the left lung could be discovered, yet the heart was 
displaced, and the dyspnea, tachycardia, acrocyanosis and debility 
were so pronounced as to completely disable the patient, even though 
there was no active tuberculous lesion to be discerned, and the tem- 
perature had been normal for a long time. While most of these patients 
are below normal in weight, I have seen many who were quite corpulent, 
and the obesity contributed to their misery. The diagnosis is made 
from the history of repeated attacks of pleurisy, cardiac displacement 
and, very frequently, the absence of breath sounds over the upper 
third of the affected lung. Many of these cases are considered as non- 
tuberculous apical lesions, notably collapse induration (see p. 474). 

Apical pleurisy is another variety of tuberculous disease limited 
to a portion of the pleura which is not generally appreciated to the 
extent it deserves. Many cases of tuberculosis with negative sputum, 
as well as doubtful cases in general, are in fact apical pleurisy which 
is not properly diagnosticated. Emil Sergent 1 and M. T. German 2 

1 Presse medicale, 1916, xxiv, 369. 

2 ifitude sur le syndrome de la pleurite apicale dans le tuberculose pulmonaire, These 
de Paris, 1916-17, No. 30. 



PRIMARY TUBERCULOSIS OF THE PLEURA 427 

have recently made a careful study of this condition and shown that 
it occurs more frequently than it is diagnosticated. 

It has already been shown that the pleura covering the apex of the 
lung is almost invariably implicated in cases of tuberculous lesions of 
the upper lobe of the lung. But at times the pleural lesion is primary, 
and its symptoms precede those of the pulmonary lesion, or it is not at 
all followed by an apical process. The symptoms presented are 
suggestive of phthisis, but physical examination and radiography fail 
to elicit conclusive signs of a localized lung lesion and the patient is 
either pronounced non-tuberculous, treated as a case of incipient 
phthisis with negative sputum, considered as suffering from some non- 
tuberculous apical lesions, etc. Many cases of abortive tuberculosis 
(see p. 385) are in fact tuberculous apical pleurisy. 

The onset is insidious. The patient is troubled with mild fever, 
unproductive cough, pain in the chest or shoulder and, coupled with 
anorexia, there is observed a constant loss in weight, though rapidly 
progressing emaciation is uncommon . I have also noted that the tachy- 
cardia characteristic of phthisis is lacking in most cases. Physical 
examination of the chest shows either slight or no impairment of reso- 
nance over the affected area during the early period of the illness. On 
auscultation the breath sounds are diminished or abolished; in some 
cases cog-wheel breath sounds are heard. Auscultation yields one sign 
which is characteristic: A friction sound is heard in the supraspinous 
fossa of the affected side of the chest. Its location is usually the 
"alarm zone," which has already been described (see p. 336). This 
friction sound is heard as occurring very superficially and it is diffi- 
cult to differentiate it from crepitation. It is heard only for a few days 
and disappears, to reappear during an exacerbation of the process. 
Its characteristics have been well described by Thomas Clifford All- 
butt: 1 "Its significance cannot be overrated. It is not far from an 
axiom to say that a streak of pleurisy, audible at the apex, means 
pulmonary tuberculosis." It is recognized by an elusive apical rub, 
"as if it were rather a creaking of a stiff membrane than a translation 
of surfaces." A faint creak may be all that is heard; it is often simu- 
lated by some fortuitous little wheeze or chirp. 

The following guides may be of service in differentiating this rub 
from crepitation: With crepitation there almost invariably is some 
alteration in the breath sounds, which are either bronchovesicular or 
bronchial, while with a friction sound they are either feeble, or com- 
pletely abolished; exceptionally there are cog-wheel breath sounds. 
Cough will accentuate crepitation, rarely abolish it, while a friction rub 
is not influenced by it. In most cases frictions are audible during 
both the inspiratory and expiratory phases of respiration, while 
crepitation is only heard during inspiration. 

Sergent has pointed out two other symptoms of apical pleurisy 

1 Lancet, 1912, ii, 1485. 



428 TUBERCULOSIS OF THE PLEURA 

which are of great assistance in the diagnosis. They are: (1) In- 
equality of the pupils; (2) Swelling of the glands in the supraclavicular 
fossa. These two signs may be found singly or in combination. 

Inequality of the pupils is observed very early, and when found in a 
patient who coughs and shows a friction rub in the supraspinous fossa 
is to be taken seriously. The pupil on the side corresponding to the 
affected pleura is somewhat dilated. It is best observed when the 
patient is made to fix his gaze upon a distant dark object and it dis- 
appears when a strong light provokes a strong contraction of the iris. 
The extent of the pupillary dilatation varies from day to day, and in 
some cases it persists after the pleural lesion has healed . 

The enlarged supraclavicular glands are mainly found in the angle 
formed by the inner extremity of the clavicle and the sternal tendon 
of the sternomastoid muscle. If they are enlarged, light palpation of 
that region will reveal these glands in most cases. In patients with 
large muscles of the neck the palpation must be done delicately while 
the patient has his muscles relaxed by bending his head toward the 
affected side. The swelling of these glands occurs late, after the disease 
has lasted for some time. In fact, when it does occur there are, as a rule, 
already signs of a parenchymatous lesion in the apex, at times even 
positive sputum. Occasionally the swelling is quite marked, but in 
most cases it is insignificant and requires careful palpation of the 
region before it is appreciated. Moreover, we must be careful before 
pronouncing palpable structures as enlarged glands. The tendon of 
the homohyoid, or the external jugular, may be mistaken for enlarged 
glands. 

In a large proportion of cases patients also complain of pain in the 
shoulder or the back beneath the scapula. This is usually a dull pain, 
uninfluenced by respiration, cough, or the position of the body. 

The course of apical pleurisy is mild in most cases. The patient 
coughs for some weeks or months and recovers. When the cough, 
fever, pain, etc., have disappeared the patient may feel well indefinitely, 
but on percussion we find that the resonance over the affected apex 
remains impaired, and the supraclavicular fossa is deeply excavated. 
The breath sounds remain feeble, or some sibilation may be audible. 
It is clear that these signs are indications that the pleura in that region 
has remained thick and adherent. Though no relapse has occurred, 
these patients are often erroneously diagnosed as tuberculous when 
they have common colds, or some other non-tuberculous respiratory 
affections, and the physician carefully examines the chest. Radio- 
graphy may confirm the diagnosis of phthisis by showing a distinct 
narrowing of the pulmonary field and some opacity of the apical paren- 
chyma; the so-called ground-glass appearance is very commonly seen, 
owing to thickening of the pleura and cicatricial contraction of the apex. 
But, as has repeatedly been stated, only constitutional symptoms 
should decide in these borderland cases whether the patient is sick 
with active phthisis requiring treatment. 



PRIMARY TUBERCULOSIS OF THE PLEURA 429 

Apical pleurisy is likely to recur. In some patients under my care 
there have been several relapses at irregular intervals, until finally the 
symptoms of pleurisy merged into those of active pulmonary tuber- 
culosis — the process invaded the parenchyma and symptoms and 
signs of an apical lesion could be made out. It is among these cases that 
strictly localized lesions are encountered — the parenchyma may be 
completely destroyed in the upper lobe, leaving a dry cavity and the 
patient recovers. In others the lesion extends, may invade the other 
lung, and chronic phthisis of the usual type pursues its course. 

In the majority of cases, however, tuberculous apical pleurisy pursues 
a very benign course. The patient has slight fever for a few weeks, 
coughs for a variable period without expectorating, has slightly enlarged 
glands above the clavicle and inequality of the pupils, while auscul- 
tation shows a friction rub over the supraspinous fossa. Within a few 
weeks to three months recovery may be complete, though there is 
likelihood of a recurrence of the trouble. 

Primary Pleurisy with Effusion. — A pleural effusion is very com- 
monly the first indication of phthisis. Numerous patients give a history 
of fairly good health when, after exposure, they were laid up with cough, 
fever, pain in the chest, dyspnea, etc. Within a few days physical 
exploration of the chest shows the presence of fluid in the pleura which 
is confirmed by an aspirating needle. It is not rare to meet with 
patients who say that they have felt out of sorts for some weeks, per-" 
haps thev have coughed somewhat, or have been slightly short-winded 
and unable to pursue their usual vocation efficiently, but still they 
have thought little of it. An examination reveals an effusion in one 
side of the thorax, though at no time have they had pain in the chest. 

It is important in these cases to inquire carefully into the history of 
the patient. A large proportion of these "primary" pleurisies is in fact 
secondary to a long-standing, but unrecognized, phthisis. While the 
patient says that he had felt quite well, interrogation often elicits the 
information that he had coughed for many weeks or months before 
the onset of the symptoms of pleurisy; perhaps that he had hemop- 
tysis many months or years before, but had completely recovered. 
In fact, his physician had told him that the symptoms indicated 
merely a trifling derangement, a "cold," gastritis, neurasthenia, etc. 
But with the arrival of the new symptoms — the painful cough, the 
fever, the pain in the chest, the dyspnea — things took a different 
aspect. It is thus clear that the patient has been tuberculous for a 
long time, and only with the arrival of the symptoms of pleurisy with 
effusion he decided that he must be carefully examined. Under the 
circumstances, a patient with pleurisy who has been ailing for some 
time before the arrival of the acute symptoms is to be considered 
tuberculous and treated as such. 

I have observed a certain number of cases of pleurisy with effusion 
which began with hemoptysis. In fact,* in several cases the disease was 
ushered in with a profuse hemorrhage. All these turned out to be tuber- 



430 * TUBERCULOSIS OF THE PLEURA 

culous. In one case the effusion was absorbed and the patient felt well 
for five years and then developed phthisis. It has been my practice 
to consider all pleurisies accompanied by hemoptysis as tuberculous. 

The temperature of the patient is in most cases high, 102° to 104° F. 
is not uncommon. It is usually slightly remittent in type; during the 
morning hours it may be one or two degrees lower than during the after- 
noon or evening. It is not due altogether to the absorption of toxins 
from the effusion, but appears to be the reaction of the body against 
the invading enemy. In fact, the young, the vigorous, have higher 
fever than the weak, the decrepit and the aged, and in many cases the 
fever abates long before the absorption of the fluid. The fever is 
accompanied by the usual symptoms of pyrexia, anorexia, backache, 
insomnia, etc. After remaining high for about one or two weeks there 
is shown a tendency to a decline in the temperature and within three or 
four weeks the patient may be completely afebrile, irrespective of the 
presence or absence of fluid within the pleural cavity. 

The pulse is accelerated in nearly all cases, corresponding to the 
degree of the fever. In some cases tachycardia is severe, and a pulse- 
rate of 120 or more is observed. The cyanosis, which is common to 
some degree in nearly all cases, may then be appalling. In rare instances 
in which failure of the circulation is accentuated there may be edema of 
the extremities; unilateral edema of the face, arm, chest, and leg, cor- 
responding to the affected side of the pleura is occasionally observed. 

Dyspnea is another symptom which is not lacking in most cases. 
In some it is merely objective. Though the patient believes that he is 
not short winded, we clearly see that he is, and the respirations are found 
thirty or forty per minute. During the first few days the dyspnea is 
often due to the pain, while later the pleural effusion, cardiac displace- 
ment, and weakness are responsible. With the beginning of absorption 
of the pleural fluid the dyspnea lets up and finally disappears when 
complete absorption has taken place. 

Physical Signs. — A physical exploration of the chest shows that the 
affected hemithorax is larger than its mate, the intercostal spaces 
obliterated and, when the exudate is copious, they may even bulge out. 
This is in contrast with the average phthisical chest in which the inter- 
costal spaces are deeply indented and there are inspiratory retractions 
to be observed. Inspection may also show the sign of the spinal muscles 
which has recently been described by Felix Ramond. 1 On the affected 
side the erector spinas is in a state of permanent reflex contraction. 
On inspection the muscular mass on the affected side appears to be 
more prominent and broader than on the sound side. On palpation the 
muscles give a sensation of hardness and resistance which may be com- 
pared to that of India-rubber slightly stretched, which differs markedly 
from the sensation elicited in the muscles on the sound side. If disease 
of the spine is excluded, this is a fairly reliable sign of an effusion into 

1 Bull, et mem. Soc. med. d. hop. de Paris. 1910, xxix, 747. 



PRIMARY TUBERCULOSIS OF THE PLEURA 431 

the pleura. Very small effusions, which escape physical diagnosis and 
even radiography, may thus be detected. 

Percussion elicits a flat note 0A*er the site of the effusion, while above 
the level of the fluid the note is tympanitic. The various lines described 
by Garland, Ellis, and Demoiseau may be made out by light percussion 
along the upper level of the fluid (Fig. 77). One important sign is 
flatness over the left hypochondrium, Traube's space, in effusion into 
the left pleura. In two out of three cases small effusions may be 
detected there early, but there are some important exceptions: It 
remains resonant, or tympanitic, in one out of three cases of moderate 
effusions. In small women with narrow chests a small effusion of about 
1500 cm. of fluid may efface that space, but in large men with capacious 
chests a large effusion may leave it with clear resonance, especially 
when the patient has been kept in bed for several days and the fluid 
sank to the posterior aspects of the pleural cavity. I have observed 
many cases in which the effusion was copious, but because of old adhe- 
sions and thickening of the anterior aspect of the pleura, there was no 
sinus into which the fluid could penetrate anteriorly and it only filled 
up the chest posteriorly. On the other hand, in some cases of effusion 
into the right pleura, Traube's space is dull or flat on percussion owing 
to displacement of the left lobe of an enlarged liver downward and to 
the left. 

The upper level of the effusion may be made out easily by light per- 
cussion. It will be found that no straight horizontal line can be drawn 
as in hydropneumothorax when the patient is in the upright position. 
As has been shown by Calvin Ellis, of Boston, in 1873, "when a pleural 
effusion is small, it may occupy a conical section of the pleural cavity in 
the subaxillary region, where respiration and resonance may be wanting. 
But in a certain number of cases, when the effusion is quite large, if an 
accurate line be drawn, the flatness will be found to describe a curve 
gradually approaching the spine toward the base of the chest, leaving a 
space from one to three inches broad between the spine and the line of 
flatness. In this space resonance will still be detected and respiration 
heard." George W. Garland, experimenting on animals, confirmed the 
tendency of fluids in the pleural cavity to form a curved outline, the 
highest point of which is in the midaxillary or scapular region, declining 
as it proceeds forward on the anterior wall of the chest, and to a lesser 
degree on the posterior aspect (Figs. 77, 78 and 79). Of the various 
explanations which have been given for this curved line indicating the 
upper level of the effusion, the most plausible appears to be that while 
attempting to make room for itself, the fluid will compress the least 
resisting parts of the walls of the pleural cavity. The mediastinum, 
which is very mobile when not held by strong adhesions, is pushed to 
the opposite unaffected side. After this has reached its limits, the lung 
will be compressed. At its roots the lung is held strongly, but at the 
sides the spongy tissue, when not held by adhesions, is easily com- 
pressible and by retraction will recede, permitting the fluid to accumu- 



432 



TUBERCULOSIS OF THE PLEURA 



late more along the sides of the pleural cavity. For this reason Gar- 
land's line is only found in large effusions; when there is but little fluid, 




Fig. 77. — Ellis's line in pleural effusions. 



Fig. 78. — Ellis's line in pleural effusions. 




Fig. 79. — Ellis's line in pleural effusions. 



the upper level is practically horizontal. Moreover, this curve can only 
be mapped out when the patient is in the erect posture; lying down 
produces a change in the line indicating the upper level of the fluid. 



PRIMARY TUBERCULOSIS OF THE PLEURA 433 

Many authors speak of shifting of the upper level of the fluid accord- 
ing to the position of the patient, and some say that it can be demon- 
strated in most cases. But experience has taught me that it does not 
occur in pleurisy, and when it is found we are dealing with hydropneu- 
mothorax. The outlook here is quite different from that in sero- 
fibrinous pleurisy. Recent investigations of this subject by H. K. 
Dunham 1 with the aid of skiagraphy has shown that "as a general rule 
it can be stated that pleural effusion does not move and that movable 
dulness over the thorax means hydropneumothorax." There are, 
however, some exceptions. Soon after tapping a chest it may be ob- 
served. But here again it has been my impression that some air had 
entered the pleural cavity during the operation. Dunham quotes 
William S. Thayer to the effect that pleural effusions move when there 
is an old emphysema of the lung above it; and Roger Morris teaches 
that transudates, such as are observed in cardiac and renal diseases, 
will move. However, I agree with Dunham who found in more than 
100 cases of pleural effusion associated with tuberculosis of the lungs, 
it could be demonstrated by the use of the roentgen rays that the 
fluid does not move as much as half an inch. This is, in fact, of immense 
diagnostic and prognostic importance, because if we find shifting of the 
dulness we are to conclude that we deal with a hydropneumothorax, or 
perhaps with a mediastinal neoplasm in which the prognosis is much 
graver than in primary tuberculous pleurisy or in simple effusions dur- 
ing the course of phthisis. 

Another sign of fluid in the pleura is a triangular area of dulness 
elicited near the spine on the uuaffected side of the chest, " Grocco's 
triangle." In his first communication on the subject, Grocco 2 described 
it thus: 

"Paravertebral triangle of the side opposite that of the pleural 
effusion. When, with a pleural effusion of sufficient size, one percusses 
from above downward, along the spinous processes of the vertebrae, 
with the patient in the sitting posture, there appears, at the level of 
the fluid, a dulness which, relative at first, becomes absolute as one 
passes downward, iu association with a progressively increasing sense 
of resistance. In like manner, by percussing downward on the 
healthy side, along lines parallel to the spinous processes, there is 
noted, opposite the dulness in the median line, a paravertebral area 
of deficient resonance, of triangular shape. One side of this dull area 
is represented by the line of the spinous processes; another, by the 
lower border of the area of thoracic resonance of a short distance, which 
varies in length from two to three or more centimeters; the outer side 
is represented by a line which, starting from the base, rises obliquely 
to unite at an acute angle with the median line at about the upper 

1 Tr. Nat. Assn. Study and Prevent, of Tuberc, 1917, xiii, 181. 

2 Riv. critica di clin. med., 1902, iii, 274; Lavori di congres. di med. int. (1902), 
Roma, 1903, p. 190. 

28 



434 TUBERCULOSIS OF THE PLEURA 

limit of dulness. In a right-sided effusion, other things being equal, 
the paravertebral triangle has seemed to me more marked." 

This triangle is found in nearly all cases of pleural effusion, and in 
rare cases of pneumonia, hydro- and pyopneumothorax, and cancer 
of the lung. It disappears when the patient reclines on the affected 
side. 

Auscultation shows that the friction sound, which was audible 
earlier in the disease, has disappeared. The breath sounds are either 
feeble or completely absent in copious effusions. In cases which are 
followed from day to day, it may be noted that the intensity of the 
breath sounds diminishes, and distant bronchial or tubular breathing 
makes its appearance. In cases in which the effusion fills two-thirds of 
the affected pleura cavernous breath sounds may be heard. In patients 
in whom there have been signs of active lesions in the lung, these signs 
may remain in the lung above the upper level of the fluid, they may 
become accentuated, or disappear, when the fluid is so considerable in 
quantity as to compress the entire lung. Bronchophony is heard in 
large effusions, and in some cases whispered pectoriloquy, both of which 
are, however, also audible in other conditions involving condensation 
of lung tissue, or thickening of the pleura, or excavation of the lung. 
In some cases typical egophony may be heard, but it is at times also 
audible in pneumonia, and even in thickened pleura. 

At times we may hear over the part of the chest filled with an effusion 
any kind of rales, or crepitation. They are usually derived from the 
catarrhal condition of the fine and medium sized bronchi which have not 
been completely compressed by the effusion. In these cases, which 
are not very rare, the diagnosis is often very difficult, but a consider- 
ation of the other signs, especially the displacement of the mediastinum, 
decides the diagnosis. 

In all cases the vocal fremitus is absent over the site of the effusion. 
But this is diagnostically of little value in chronic cases of tuberculosis 
because this is also observed iu thickened pleura. 

Displacement of Organs. — In pleurisy with effusion the mediastiuum 
is displaced toward the unaffected side of the chest, provided the 
exudate is ample. In effusions into the right pleura the liver may be 
pushed downward and felt beneath the costal arch, while in effusions 
into the left side the spleen may, at times, be felt down in the abdomen, 
and the stomach also is often displaced downward. The weight of 
the fluid is sufficient to displace these abdominal organs. It is Douglass 
Powell's opinion that it is not the amount of fluid that is instrumental 
in displacing the heart in pleurisy with effusion. Rokitansky, Frank 
Donaldson, and others, have shown that no real pressure is exerted on 
the heart till the pleura is more than two-thirds filled. Small effusions 
may displace the heart by diminishing or abolishing the elastic retrac- 
tion of the lung in the unaffected side of the chest. 

Exploratory Puncture. — In nearly all cases these signs suffice to prove 
that there is an effusion, and its location. But this should be con- 



PRIMARY TUBERCULOSIS OF THE PLEURA 435 

firmed by exploratory puncture, both for general diagnostic purposes, 
as well as with a view of ascertaining the nature of the fluid. While 
in tuberculous pleurisy, as well as in all other conditions, exploratory 
puncture is a harmless procedure, yet at times we meet with some 
trouble, such as the conversion of a pleurisy into a hydropneumothorax. 
For this reason, if the general condition of the patient is good, we may 
leave the effusion alone. But in case the temperature continues high or 
hectic for more than two weeks, there are chills and, perhaps, some edema 
of the chest wall, especially if the patient begins to lose ground after 
the appearance of the exudate, an exploratory puncture should be made 
under strict aseptic precautions. Exploratory puncture is also indi- 
cated in doubtful cases, when differentiation between an effusion and a 
thick pleura is aimed at. But here when we get a dry tap we are just 
as much in the dark as before. In fact, in these cases of thick pleura the 
puncture must be made very carefully. The diaphragm is high, owing 
to old adhesions in various parts of the pleura, and when the needle is 
inserted low into the chest it may penetrate the peritoneum, the spleen 
or the liver and the result is a dry tap. Large flakes of fibrin, thick pus, 
etc., may be the cause of a dry tap. In such cases the needle is with- 
drawn and reinserted in another place, but I have known of many cases 
in which several exploratory punctures proved negative, while incision 
of the chest wall showed that there was an effusion. 

Exploratory puncture is also dangerous during the first few days 
of the appearance of the effusion. It should be avoided during the 
febrile stage, because it is liable to spread the tuberculous infection by 
producing a bacteremia. In all cases in which it is feasible puncture 
should be postponed till the fever abates. 

Examination of the Exudate. — The fluid withdrawn should be placed 
in a sterile tube and carefully examined. As will be shown later on 
(see p. 448), tubercle bacilli are found only exceptionally in pleural 
exudates. But various other microorganisms should be sought, espe- 
cially streptococci, staphylococci, pneumococci, etc. Sterile pus, which 
is not extremely rare in pronounced tuberculous cases of phthisis with 
empyema, is of good prognostic significance. But in primary empy- 
emata it is never found. It has been stated by several authors, not- 
ably Widal, Wolff-Eisner, and others, that the cytological investi- 
gation of the exudate is of diagnostic importance. When lymphocytes 
predominate in the centrifuged sediment, the pleurisy is of tuber- 
culous origin, while if polynuclear leukocytes predominate, the cause 
is one of the pyogenic microorganisms, notably streptococci. But 
it has been my experience that pyogenic microorganisms are found in 
most tuberculous pleurisies, owing undoubtedly to mixed infection. 
But now and then we find a case of sterile pus in tuberculous pleurisy 
and, as has already been stated, the prognosis is very good when this is 
the case, provided the pleura is not infected by repeated exploratory 
or therapeutic punctures. Therefore the cytology of the fluid should 
be ascertained in every case. It can be accomplished very easily by 



436 TUBERCULOSIS OF THE PLEURA 

centrifuging the fluid and making a smear of the sediment, staining it 
with Loftier' s methylene blue solution. 

Skiagraphy. — With the .r-rays we find that the fluid in the chest casts 
a deep, homogeneous shadow in the affected part of the chest. The 
diaphragm is immobilized and the costophrenic sinus is abolished. 
The upper limit of the fluid is not marked by a sharp line of demarca- 
tion between the lung tissue above and the fluid below (Plate XXI, 
Fig. 4), as is the case in hydropneumothorax. The shadow passes 
gradually from the deep opacity of the fluid to the luminous part of the 
lung tissue above. This is due to the fact that the lung immediately 
above the fluid is compressed and airless to a degree, and is therefore 
not so clear on the screen or plate as the portions higher up, where air 
enters freely. Garland's, Ellis's, or Demoiseau's lines may be made out 
in many cases as a convexity of the upper level of the fluid in the axilla. 
In most cases it will be noted that the brightness and clearness of the 
upper lobe of the lung are not so pronounced as in the opposite unaffected 
side. But this should not lead us to the conclusion that there is a 
pulmonary, or perhaps a tuberculous, lesion without further investi- 
gation. Because the lung is compressed above the fluid, and often quite 
congested, it does not permit the rays to pass as freely as in the opposite, 
usually vicariously emphysematous lung. 

The diaphragm in all cases of pleurisy w r ith or without effusion is 
immobile. When there is an effusion it may be seen on the screen in 
left-sided cases while in right-sided effusions the shadow merges with that 
of the liver. Barjon 1 points out that the immobilization precedes the 
arrival of the fluid and remains long after the fluid has been absorbed. 

The trachea and the mediastinal organs, especially the heart, are 
shifted toward the unaffected side of the thorax. This point is occasion- 
ally difficult to make out in tuberculous cases. But the roentgen rays 
clear it up at once. 

With the aid of the .r-rays we may follow the effusion, noting care- 
fully its amount, its tendencies to increase, or its absorption, and 
especially whether the lung shows a tendency to reexpand after the 
effusion is absorbed. On these points, the roentgen rays are superior 
to physical diagnosis in many cases. 

Course. — In non-tuberculous pleurisy the effusion is absorbed within 
a few weeks in the majority of cases. Only exceptionally does the fluid 
remain within the chest for more than two months. In tuberculous 
pleurisy the rule is that the effusion persists for months. Moreover, 
in non -tuberculous pleurisy the fever shows a tendency to abate after 
the effusion is tapped; often even when the fluid remains within the 
chest. It is different with tuberculous pleurisy. Here tapping does not 
render the case afebrile; at most, it reduces it one or two degrees. 
In fact, in many cases the reverse is often observed. The fever may be 
trifling, but tapping the chest brings about an elevation of the tem- 

1 Radiodiagnostic des affections pleuropulmonaires, Paris, 1916, p. 35. 



PLEURISY DURING THE COURSE OF PHTHISIS 437 

perature. The reason is obvious. While the effusion is within the chest, 
the diseased lung and, with it, the tuberculous lesion is compressed; 
toxemia is thus prevented as is the case with artificial pneumothorax. 
With the removal of the fluid the lung lesion reactivates and produces 
fever with its concomitant phenomena. 

It is for this reason that I am averse to tapping pleural effusions 
indiscriminately. I have felt that in many cases the outlook for the 
patient might have been better had the fluid been permitted to remain 
in the chest. Of course, individualization is to be practised. When the 
dyspnea becomes threatening, or the fever is very high, the question of 
tapping is to be given consideration. 

In all cases in which despite the mildness of the general symptoms, 
the fluid shows no tendency to absorption, tuberculosis is to be looked for. 

After the fluid has been absorbed the patient with non-tuberculous 
pleurisy begins to improve in general health. His appetite returns, he 
gains in weight and strength, and the signs in his chest may disappear 
at times without leaving any trace. In many cases some thickening 
of the pleura may be detected on physical exploration of the chest. 
But this is no indication that he has remained sick. It is different with 
tuberculous pleurisies. The effusions may persist within the chest for 
months. I have seen cases in which it persisted for mDre than two 
years. When it is finally absorbed, the physical signs in the chest show 
unmistakable signs of a tuberculous lesion in the apex of either side, 
while over the lower lobe, at the base, signs of thickened and adherent 
pleura may be easily discerned. In a large proportion of cases the 
pleural adhesions dislocate the mediastinum toward the affected side. 
This is in contrast with the location of the mediastinum while the 
fluid was in the chest. It has been my rule to consider a thick pleura 
with dislocation of the heart toward the affected side as of tuberculous 
origin, irrespective of the constitutional symptoms presented. Still, 
it does not always mean active tuberculosis. In many cases of bron- 
chiectasis, especially on the left side, dislocation of the heart is seen. 

During the course of pleurisy with effusion the pulmonary apex of 
the unaffected side is to be watched for signs of a tuberculous lesion. 
Very frequently a timely diagnosis is thus made. In experimental 
tuberculosis of the pleura both sides are usually found affected though 
the inoculation has been made only on one side, as has been shown by 
Robert C. Paterson. For this reason we may find an active tuberculous 
lesion in the lung with the unaffected pleura, though as a ride the lesion 
is in the lung in whose pleura the effusion is found. 

Of course, the sputum is to be examined for tubercle bacilli at fre- 
quent intervals during the course of the disease. 

PLEURISY DURING THE COURSE OF PHTHISIS. 

As has already been stated, during the course of phthisis, the pleura 
is implicated sooner or later in practically every case. There is hardly 



438 TUBERCULOSIS OF THE PLEURA 

a case of active, or healed, tubercle of the lung in which pathological 
changes cannot be made out in the pleura at the necropsy. The blood 
supply of the pleura, as well as its lymphatic system, shows that tubercle 
bacilli in the lungs, or the thoracic glands, almost inevitably must find 
their way into the pleura (see p. 419). Dry adhesive pleurisy is the 
result of the extension of the tuberculous process to the pleural mem- 
brane, in most cases. Severe cough, tugging upon these adhesions, or 
tearing them apart, may thus produce inflammation of the pleura. The 
pleurisy in such cases is, strictly speaking, of traumatic origin. 

The most common variety of pleurisy in individuals suffering from 
chronic phthisis is the dry, adhesive form, affecting only part of the 
pleura, notably that overlying the affected lung area; the areas found 
affected in the order of their frequency being the apical, that lining the 
interlobar fissures, the diaphragmatic, and the mediastinal pleura. As 
a rule, the pleura reacts to irritants by a productive inflammation lead- 
ing to adhesions of the affected areas. At times the inflammation is of 
the exudative variety and an effusion takes place into the pleural 
cavity. This effusion may be serous, serosanguineous, or purulent; it 
may fill the entire pleural cavity, or only part of it ; it may be general, 
localized, or encapsulated. 

Pleurisy Accompanying Acute Phthisis. — In the acute forms of 
pulmonary tuberculosis the pleura is usually found studded with 
tubercles. In most cases the effusion is rather small and negligible 
from the diagnostic standpoint and in many cases it is serosanguineous. 
In rare cases the effusion is copious and may even mask the underlying 
progressive tuberculous process in the lungs, as I have seen several 
times. The symptoms of acute miliary tuberculosis, or of acute pneu- 
monic phthisis, are clear cut; the patient is prostrated with high fever, 
profuse sweats, rapid heart action, distressing dyspnea, cyanosis and 
emaciation. In the miliary cases there may be cerebral symptoms, while 
in the pneumonic cases distressing unproductive cough may be domi- 
nating. Severe anemia and emaciation appear early and proceed at a 
rapid pace. But physical exploration of the chest revealing an effusion 
into the pleural cavity, we are apt to be misled and consider it a simple 
case of pleurisy, and raise false hopes in the patient and his friends. In 
fact, we are justified in our favorable opinion, because it is extremely 
rare that a patient with a primary pleural effusion should succumb. 
But the fever keeps on despite tapping the pleura, and the severe 
constitutional symptoms do not abate. Indeed, instead of relieving the 
dyspnea, as is usual in many cases, tapping aggravates it. 

Within a short time signs of consolidation of one of the upper lobes 
of the lungs will be noted ; the patient begins to expectorate consider- 
able quantities of mucopurulent sputum which, as a rule, contains 
tubercle bacilli. Signs of excavation soon make their appearance in 
either lung. In the acute miliary cases symptoms of meningitis may 
be the terminal phenomena. 



PLEURISY DURING THE COURSE OF CHRONIC PHTHISIS 4.'W 

Pleural effusions, especially serosanguineous, characterized by high 
fever, prostration, cyanosis, tichycardia and emaciation should be given a 
guarded prognosis. If there is a history of cough, expectoration, loss in 
weight, etc., for some weeks or months before the onset of the acute 
symptoms, the cue should be taken and a careful search should be made 
for proofs of the underlying acute pulmonary process. 

PLEURISY DURING THE COURSE OF CHRONIC PHTHISIS. 

We have already stated that many of the so-called "primary" 
pleurisies are really secondary in the full sense of the word, because the 
patients had been coughing, losing in weight, sweating, etc., for some 
time before the appearance of the pleural symptoms. But in the vast 
majority of cases of pronounced chronic phthisis there are to be dis- 
cerned symptoms and signs of pleurisy at one time or another. Pain in 
the chest during the course of tuberculosis is almost invariably due 
to pleurisy. As was already stated (see p. 254), the lung contains no 
sensory nerves and only when the pleura is implicated will the patient 
have pain iu the chest. 

Dry pleurisy of this type may be localized and circumscribed in any 
part of the chest, and may be bilateral. Its most common location is 
the apex; but the base, and especially the diaphragmatic pleura, are 
affected in a large proportion of cases. Usually the fibrinous exudate 
becomes organized, and the two sheets of the pleura are glued together 
by adhesions. Often large, thick strands of adhesions are seen radio- 
scopically, or at the necropsy, running from the diaphragmatic pleura 
into the depth of the lung (Fig. 2, Plate XVII). Over the apex the 
adhesions are frequently seen forming a thick fibrous shell around the 
diseased area. In cases with large excavations, the thick, adherent 
pleura may be the only structure left instead of the upper lobe of the 
lung. 

Symptoms of dry pleurisy may be encountered during the course of 
phthisis in any of its stages. The pain in the chest is felt in the neighbor- 
hood of the affected pleura, or may be referred (see p. 424) and then it is 
felt over the shoulder, the abdominal walls, etc. During the course of 
phthisis pains in the shoulder, which may become severe and intract- 
able, should not be pronounced "rheumatic," but a careful search 
should be made for physical signs of diaphragmatic pleurisy. Similarly, 
pain in the abdomen should not be attributed to gastric ulcer, appendi- 
citis, cholelithiasis, etc., but a search should be made for signs of 
diaphragmatic pleurisy. In many cases a friction sound may be heard 
over the affected part of the pleura, but in others the adventitious 
sounds emanating from the parenchymatous lesions obscure it and 
render it doubtful. 

Symptoms. — Phthisical patients have no pains so long as the pleura 
is not implicated. When they get pain in the chest, they are apt to 
attribute it to a " cold." After a chill, or any exposure, they may feel 



440 



TUBERCULOSIS OF THE PLEURA 



a sharp, at times a lancinating, pain in the chest, aggravated by 
cough or deep breathing. The temperature, if normal before, becomes 
elevated to 101° F. or 102° F. Dyspnea may be distressing owing to 
the pain during respiratory efforts. 

Inspection may be of little value, because the phthisical chest already 
shows lack or impairment of the mobility of the chest owing to the 
parenchymatous tuberculous process; the same is true of percussion. 
Auscultation reveals a friction sound over the affected area, while the 
breath sounds are usually feeble. This friction sound is, at times, diffi- 
cult to differentiate from adventitious sounds of intrapulmonary origin. 
It is, however, sufficient to bear in mind the following points: Intra- 
pulmonary rales are usually audible as occurring during the inspiratory 
phase of respiration, or during the second half of inspiration, while 
frictions are heard during both phases, inspiration and expiration. 
Friction sounds are audible as if coming from a point near the bell of 
the stethoscope, while intrapulmonary rales appear more distant. 
Cough will influence the character of intrapulmonary rales, usually 
accentuating, rarely abolishing them, while frictions remains the same 
even after intense respiratory efforts by cough. Pressure of the bell of 
the stethoscope against the chest wall may intensify a friction sound, 
while rales remain unaffected. 

These signs are more or less easily made out when the pleural lesion 
is located in the lateral aspects of the chest, especially over the lower 
lobes of the lungs and anteriorly. But when the process affects the 
pleura over the apex of the lung, over the diaphragm, of the medi- 
astinum, it may be difficult to localize the pleural lesion. Over the 
apex friction sounds may be easily mistaken for small, moist rales, or 
crepitation, and some authors have been inclined to attribute most of 
the above-mentioned sounds, when heard over the apex, to friction 
sounds, alleging that incipient phthisis is always accompanied by 
pleurisy, and the sounds are due to frictions (see p. 305). Deep breath- 
ing, however, will accentuate intrapulmonary sounds, while frictions 
are not thus influenced. Feeble breath sounds speak in favor of pleu- 
risy, especially when the pleura is thick. Crepitation is almost invari- 
ably accompanied by bronchovesicular or bronchial breathing. With 
feeble breath sounds large, moist, consonating rales are invariably of 
intrapulmonary origin. 

Pleural Adhesions. — Dry pleurisy in pronounced phthisical subjects 
has an important influence on the course of the underlying disease of the 
pulmonary parenchyma. In addition to the painful suffering it inflicts, 
it is liable to terminate in an effusion. But this is exceptional. In 
most cases adhesions result. Very often, by limiting the motion of the 
affected parenchyma, as well as through some as yet not understood 
biochemical and immunological processes, these exudates and adhe- 
sions impede the progress of the tuberculous lesion in the lung, retard 
the progress of the disease, and improve the prognosis in general. 

In most cases the adhesions are limited to the area of the pleura 



PLEURISY DURING THE COURSE OF CHRONIC PHTHISIS 441 

immediately overlying the diseased part of the parenchyma of the hmg. 
The diagnosis may be made by paying attention to the following points: 
On inspection the affected area of the chest is seen to move but slightly 
during respiration; the motion may be restricted, or there may be 
lagging over a limited part of the chest wall. Instead of expanding 
during inspiration, the intercostal spaces will be seen to retract during 
each filling of the chest. These inspiratory retractions are of immense 
diagnostic importance, but they are not infallible. They may be seen 
in cases without adhesions — when there is airless lung tissue with a 
thick visceral pleura, and this is not rare in chronic phthisis. Very 
frequently enlarged venules may be seen on the chest wall, indicating 
interference with the circulation by compression of the venous flow at 
the affected area. Moreover, owing to the retraction of the upper part 
of the pleura and lung in apical adhesions, the supra- and infraclavicular 
foss?e are deeply excavated. When the basal pleura is adherent, the 
lower part of the chest appears smaller and expands to a lesser degree 
than the opposite side. Percussion elicits an impaired note, frequently 
with a tympanitic overtone, especially when the apical pleura is affected. 
Over the base the note may be flat and, because the vocal fremitus 
is absent or defective, fluid is thought of. Friction rales are at times 
heard over the apex; feeble breath sounds are the rule. Loud, con- 
sonating rales and clicks of intrapulmonary origin may be so pro- 
nounced as to overshadow all other sounds. It is these adhesions 
over the apical pleura that interfere with the success of therapeutic 
pneumothorax in many cases. They form a thick, unyielding shell 
around the diseased apex of the lung, and do not permit it to collapse 
or to be compressed by the air which enters the pleural cavity covering 
the lower, unaffected lobes. 

When the pleura over the lower lobe is affected by adhesions, percus- 
sion may yield a normal, or even slightly tympanitic note when it is not 
much thickened. The breath sounds are almost invariably feeble in 
the lung under an adherent pleura, and tidal percussion shows that the 
affected side does not expand as efficiently as the opposite side, and that 
the diaphragm also does not move properly. Inspiratory retractions, 
while not pathognomonic, yet they are so common in pleural adhesions 
that they should be looked for in every suspicious case. However, our 
experience with the production of therapeutic pneumothorax shows 
clearly that there are no absolutely reliable signs of pleural adhesions. 
Even skiagraphy fails very frequently. In cases in which all the signs 
point to adhesions, a pneumothorax may be induced at times with ease; 
while in others, in which all the signs point in the direction of a pleura 
free from adhesions, all attempts at introducing gas fail (see Chapter 
XLII). It seems to me that only pleural adhesions with thick pleura, 
especially a thick parietal pleura, may be diagnosed, but there may be 
strong adhesions without perceptibly thickening the pleura, and it is in 
these cases that we fail frequently. It also depends on which pleura is 
thick. If it is the visceral pleura — most frequently the one affected — 



442 TUBERCULOSIS OF THE PLEURA 

we may find signs pointing to adhesions which, in fact, do not exist. 
When the parietal pleura is thickened, we almost invariably will find 
the adhesions by the usual methods. 

The X-rays in the Diagnosis of Dry Pleurisy and Adhesions. — Small 
circumscribed adhesions of the pleura are not recognized with the 
arrays. In most cases with thick, adherent pleura over the tuberculous 
apex it is impossible to state with any degree of positiveness whether 
the pleura is thick and adherent or not, because of the abnormal shadows 
produced by the parenchymatous lesion. When extensive and massive, 
a thick pleura may be recognizable, especially when the membrane 
over the lower lobes is affected. We then note that the convexity of 
diaphragm is no more a smooth line sharply demarcating it from the 
luminous lung tissue, but that it is uneven and deformed, and various 
bands of connective tissue may be noted projecting into the pulmonary 
parenchyma. The costodiaphragmatic sinus and the cardiohepatic 
angle are either obtuse or completely obliterated (Fig. 2, Plate XVII). 
The motion of the diaphragm is restricted or abolished. 

In older cases, with more extensive adhesions, the condition may be 
recognized at first glance on the screen or plate. The ribs in the 
affected side form a very acute angle descending from the spine, the 
intercostal spaces are narrower than those on the opposite side, the 
luminous lung area is of smaller extent, owing to pulmonary retraction, 
than on the opposite, unaffected side. The mediastinum is pulled to 
the affected side! The diaphragm is immobile and often elevated. 
Because of compensatory emphysema, the luminosity of the lung in 
the unaffected side is more pronounced than would be expected. 

In many cases of extensive pleural thickening and adhesions of the 
lower part of the chest, it is difficult to differentiate this condition from 
fluid in the pleural cavity, as has been intimated above. Usually the 
.T-rays clear up the diagnosis. In fluid the intercostal spaces are wider, 
the mediastinum pushed to the unaffected side, etc. But we frequently 
meet with cases in which it is very difficult or impossible to decide as 
to what we are dealing with, with all diagnostic means at our command. 
Even exploratory puncture, when it turns out negative, may not clear 
up the diagnosis. At times it is difficult to decide whether dulness and 
the shadow on the plate found in the lower part of the chest are due to 
a thick pleura or to a parenchymatous lesion. As a rule, when the 
percussion note is dull or flat, and the z-rays do not show a deep shadow, 
the lesion is probably pleural ; conversely, when the percussion note is 
but slightly impaired, or has a tympanitic overnote, we are, in all 
probability, dealing with a parenchymatous lesion. But even to this 
there are many exceptions. 

A thickened interlobar pleura cannot be diagnosed except with the 
aid of radioscopy. But it may also be missed in the radiogram, unless 
the tube is placed high, on a level with the patient's head so that the 
rays pass through the chest at an oblique angle, from above downward 
through the whole width of the thickened interlobar septum, thus 



PLATE XVII 



Fig. 1 



Fig. 2 





Localized pneumothorax in upper third 
of right side. Interlobar fissure markedly 
thickened. Extensive tuberculous changes 
in upper lobe of the left lung. 



Localized pneumothorax in right side 
of thorax. Note the thick bands of ad- 
hesions running from the diaphragm and 
mediastinum. Diaphragm elevated. 



Fig. 3 



Fig. 4 





Interlobar effusion in fissure between 
upper and middle lobe of right lung. 
Extensive tuberculous changes throughout 
right lung with cavitation. 



Complete pneumothorax in left side. 
Note the left lung compressed against the 
mediastinum which is markedly displaced 
to the right. 



PLEURISY DURING THE COURSE OF CHRONIC PHTHISIS 443 

casting a shadow of its widest and thickest surface. This is best 
accomplished by placing the tube on a level with the patient's head 
when viewing the chest anteriorly, and on a level with the sacrum 
when viewing the patient at his posterior aspect. Its appearance can 
be seen on Fig. 3, Plate XVII. 

At times we meet with interlobar effusions which may be easily 
recognized by their physical signs — a transverse band of dulness run- 
ning across the chest along the second and third interspace, while above 
and below the resonance is clear. This, in addition to bronchial 
breathing and whispered pectoriloquy, should excite suspicion of an 
interlobar effusion when there are also symptoms of pleurisy, such as 
pain in the chest, fever, cough, etc. But after all the diagnosis is made 
positively only with the aid of the .r-rays. 

On the screen or the plate (Fig. 3, Plate XVII) there will be seen an 
opaque band running across the chest below the second and above the 
fourth or fifth ribs. The lung is divided into three regions: The upper 
is more or less bright, the middle, dark, and the lower again bright. 
In the fluoroscope this suspended shadow may be seen moving with the 
respiratory movements of the chest. The motion of the diaphragm is 
practically normal. An intrathoracic neoplasm may also produce such 
a picture on the screen, but it is differentiated from an interlobar 
effusion by the clinical history of the case. 

Pleural Effusions During the Course of Phthisis. — In most cases 
the implication of the pleura in the tuberculous process passes away 
leaving adhesions and at times without leaving any obvious traces 
behind. Some patients thus suffer from recurrent attacks of dry 
pleurisy, so long as the tuberculous process in the lung remains active. 
In others, effusions occur. This may be observed during any stage of 
the disease. When occurring before the recognition of the lung lesion, 
we are apt to consider it as "primary" pleurisy, but careful inquiry 
into the past history of the patient shows the fallacy of such an assump- 
tion (see p. 429). The effusion may be serous, serofibrinous, serosan- 
guineous, or purulent. When it is serous, the fluid can hardly be dis- 
tinguished from that found in non-tuberculous cases. As will be shown 
later on, tubercle bacilli can only rarely be demonstrated in the exudate, 
and implantation on cultures, as well as inoculation experiments, are 
too often negative to be of real diagnostic value. In the serosanguine- 
ous exudates the chances of finding tubercle bacilli are greater than in 
purely serous, or serofibrinous fluid. 

Hemorrhagic effusions occur mainly in tuberculosis, but may also be 
encountered in cancer of the lungs or pleura, in pleurisy affecting 
persons suffering from certain cachectic conditions, notably scurvy, in 
certain exanthematous diseases, as hemorrhagic smallpox, and, excep- 
tionally, in persons suffering from cirrhosis of the liver, aneurism of 
the aorta, and even chronic nephritis. 

In tuberculosis of the pleura the blood is derived from the rich net- 
work of bloodvessels which are frequently seen in these processes, 



444 TUBERCULOSIS OF THE PLEURA 

especially where there is a false membrane. The physical signs and the 
symptoms of serosanguineous pleurisy are not different from those 
found in cases with serous effusions. It is only by exploratory puncture 
that the diagnosis is made. But we must guard against certain sources 
of error. While performing exploratory puncture with a thick needle 
a bloodvessel may be injured and bloody fluid is seen in the barrel of 
the syringe, though within the pleura it is clearly serous. In some of 
these cases it may be noted that the first part of the fluid entering the 
syringe is bloody, then it becomes paler, and the final part is practically 
straw-colored. Rarely the reverse is observed. The first portion is 
serous, while at the end it becomes sanguineous, evidently because the 
needle touched a bloodvessel. Moreover, after one exploratory punc- 
ture, especially after tapping the chest, when serous fluid is removed, 
a second puncture, performed some time later, may show the fluid 
sanguineous even when there is no malignant disease nor tubercle of 
the pleura. The blood is then distinctly of traumatic origin. These 
cases are responsible for the numerous instances one encounters in 
which sanguineous fluid was found in the chest and no symptoms of 
tuberculosis or cancer are subsequently observed to follow. In my 
experience sanguineous fluid is mainly found in very acute cases of 
pulmonary tuberculosis and only exceptionally in chronic cases. 

We have thus in most cases of bloody fluid to differentiate between 
cancer and tubercle. When due to malignancy, the history will show a 
slow onset, with little or no rise in the temperature. In some cases 
there may be found a relatively large number of coarsely granular 
eosinophile cells or corpuscles in the aspirated bloody fluid. In tuber- 
culous pleurisy with effusion the history points to an old tuberculous 
process, and there is marked pyrexia, excepting in the rare cases of 
latent effusions. Microscopic examination of the fluid shows a high 
lymphocyte count, in addition to the abundance of red blood corpuscles. 
But, as was already stated, the cytology of the fluid is not reliable 
diagnostically. 

Hemorrhagic effusion occurring during the course of phthisis remain 
within the pleura for long periods of time. I have seen cases in which 
they remained for longer than two years. In rare instances tapping 
once or twice will free the pleural cavity of the fluid, but in the vast 
majority the exudate reaccumulates. In some the pressure effects — 
dyspnea, cyanosis, edema of the extremities, etc. — are instrumental in 
bringing about a fatal issue; in others the tuberculous lesion in the 
lung sooner or later relieves the patient of his earthly sufferings. 

Purulent effusions are comparatively infrequent during the course 
of phthisis. Whenever they occur in my cases I am suspicious that a 
latent pneumothorax has existed; and pneumothorax is frequently 
overlooked. I have recently paid special attention to this point and in 
the majority of cases of empyema in phthisical subjects I have been 
able to discover radiographic evidence of an air pouch above the level 
of the fluid. Empyemata are thus due to rupture of the visceral pleura 



PLEURISY DURING THE COURSE OF CHRONIC PHTHISIS 445 

at some point, be the loss of continuity ever so minute, and the entry 
of air, as well as secretions from the diseased lung into the pleural 
cavity. On the other hand, it is possible that empyema may occur in 
phthisical individuals without rupture of the pleura ; the cases in which 
the pus is practically sterile testify to this. Similarly, during epidemics 
of acute respiratory infections tuberculous patients are often affected 
and empyema at times follows. The etiological agent in these cases is 
usually one of the various strains of pneumococci or streptococci. 

Symptoms. — The onset of pleurisy with effusions may be abrupt, as 
in primary cases. The patient has been getting along with his tuber- 
culosis quite well, or has been improving, when he is seized with pain in 
the chest, dyspnea, and cough. In other cases pains in the chest have 
been repeatedly felt by the patient, and recurrent dry pleurisy has 
been diagnosticated. But now there is noted an increase in the dyspnea 
while coincidentally the pain in the chest disappeared. We also meet 
with patients who give no history of any extraordinary symptoms, but 
an examination of the chest reveals an effusion. These latent pleurisies 
are not very rare in phthisical subjects. Fever is the rule, but during 
the course of active phthisis this cannot guide us because of its almost 
invariable presence in these patients. In afebrile tuberculous patients 
there is noted an elevation in the temperature with the arrival of fluid 
in the chest. 

When the effusion is in the pleural cavity it is easily recognized by 
the physical signs and exploratory puncture which have already been 
detailed above (see p. 430). But in phthisical patients localized 
effusions are very frequent, because old adhesions limit the size of the 
exudate. In addition to the interlobar exudates which have already 
been mentioned (see p. 433) there may be localized effusions in any 
part of the pleural cavity, most commonly in the pleura lining the 
lower lobes. In these cases exploratory punctures are to be made with 
circumspection. The site of the exudate should be clearly delimited 
before the needle is inserted, and the .r-rays should be used freely. 

Serous and serofibrinous exudates are apt to remain a long time in the 
chest of tuberculous patients, though we often meet with cases in which 
the fluid is absorbed within a few weeks. Purulent exudates, on the 
other hand, remain indefinitely, though I have seen several cases in 
which the pus broke through a bronchus and was expectorated, the 
patient improving. In most cases, however, the fever keeps at a high 
level, is often hectic, characterized by frequent chills, severe emaciation, 
amyloid degeneration of the liver, spleen, kidneys, intestines, etc., and 
the patient finally succumbs to exhaustion. 

The onset of purulent effusions in tuberculous subjects may also be 
very insidious. The patient has felt quite well, but of late has begun 
to lose ground; has had hectic fever, nightsweats, dyspnea, etc. In 
some patients under my observation the fever was slight, there were no 
pains in the chest, and the cough was mild. But they had been losing 
in weight and strength. An examination of the chest reveals the 



446 TUBERCULOSIS OF THE PLEURA 

presence of an effusion which, because of the mildness of the general 
symptom, is thought to be serous. But an exploratory puncture shows 
the presence of pus in the pleura. Considering the difference in the 
prognosis when serous effusions are considered, as compared with puru- 
lent effusions, it is clear that in every case the nature of the fluid should 
be ascertained by exploratory puncture — the only way in which we 
may inform ourselves as to the character of a pleural effusion. In 
many cases careful inquiry elicits a history strongly suggestive of a 
latent pneumothorax. In these cases the condition is in fact that of 
pyopneumothorax. 

PROGNOSIS IN TUBERCULOUS PLEURISY 

As is well known, the immediate outlook in tuberculous pleurisy is 
very bright in nearly all cases. It is the ultimate outlook which is of 
importance. The problems are: Will the patient, recovering from an 
attack of pleurisy, sooner or later develop active pulmonary tuber- 
culosis? If he does, will the tuberculous process be of a progressive and 
dangerous type, or will it run a slow benign course? The seriousness 
of these prognostic problems is realized by every physician whenever 
he has a case of pleurisy under his care. The entire future of his patient 
depends on this ultimate prognosis of pleurisy. 

Prognosis in Primary Pleurisy. — In dry pleurisy the immediate 
outlook is almost invariably good. Within a few days, at most two 
weeks, the fever, cough, dyspnea, etc.. abate, the pain diminishes in 
intensity and finally disappears, and the patient may be considered well. 
In many cases the friction sound is audible in the chest for a long time; 
I have found it in patients for many months after an acute attack, but 
usually it disappears within several weeks. The pains hi the chest 
at times remain indefinitely; they are apt to appear during sudden 
changes in the weather, but are usually not severe enough to disable 
the patient. 

In rare cases of dry pleurisy, strong adhesions of the pleural sheets 
are formed, and deformities of the chest may result, localized retrac- 
tions of the chest wall may be noted, displacement of the mediastinal 
organs may occur and dyspnea may torture the patient, especially in 
left-sided interlobar pleurisy. In others, with basal dry pleurisy, the 
diaphragm remains elevated and more or less immobilized, and some 
local bronchiectasis remains permanently. The result is that the patient 
keeps on coughing and expectorating for many years, perhaps for life. 
The prognosis is that of bronchiectasis, but the patient is likely to be 
told by some physicians that he is tuberculous with a basal lesion. 
Many of these patients are sent to sanatoriums during each exacer- 
bation of the cough, expectoration, etc. 

Dry pleurisy is likely to recur. One who has had one attack, as a 
rule, suffers from repeated attacks at irregular intervals. In these cases 
the pleura remains thickened, the mediastinum displaced, and bron- 



PROGNOSIS IN TUBERCULOUS PLEURISY 447 

chiectasis develops in any part of the lung. In others, the patient 
recovers from the first few attacks, but finally develops pulmonary 
tuberculosis. Recurrent attacks of dry pleurisy are therefore to be con- 
sidered as a sure sign of tuberculosis and treated as such. Especially is 
this true of apical pleurisy. 

Prognosis in Pleurisy with Effusion.— A pleural effusion is usually 
preceded by an attack of "dry" pleurisy. In fact, in all cases of dry 
pleurisy our immediate prognosis is to be guarded; we should wait 
some days, watchful for the appearance of fluid. When an exudate in 
the pleura is made out, the prognosis is not markedly aggravated. 
Death of a patient with a pleural effusion is extremely rare, especially 
now when, by tapping, we can avoid accidents due to overfilling of the 
pleura by the fluid and menacing symptoms make their appearance. 

Usually small or moderate sized effusions are absorbed within a few 
weeks and the patient recovers. In many cases, fully four-fifths, the 
disappearance of the fluid leaves the patient in excellent condition ; he 
soon regains his lost weight and strength, and an examination of his 
chest several months later may not show any traces of the disease which 
he passed through. In a large proportion of cases pleural thickening 
and adhesions remain. In some, bronchiectatic conditions remain 
indefinitely, manifesting themselves by periodical attacks of fever, 
cough, and expectoration, which may be influenced by the posture of 
the patient. In still others, the adhesions and sclerosis are instrumental 
in producing displacement of the heart, and dyspnea is a permanent 
feature which keeps them troubled for life. 

But the fluid may not be absorbed so soon. It may remain in the 
chest for many months. I have now a case under my care in which the 
fluid has not been absorbed for over two years. To remain within the 
pleural cavity for two or three months is a common observation. In 
these cases tapping is of little or no avail ; within a few days the fluid 
reaccumulates and the symptoms of intrathoracic pressure reappear. 
As a rule, when the fluid has been in the chest for a long time the fever 
abates; rarely we find a chest full of fluid in a patient with a normal 
temperature. He only coughs and is more or less short winded. In 
some of these the tapping may result in a return of the fever, cough, 
etc., to be ameliorated, or disappear when the exudate reaccumulates. 

Of course, when a serofibrinous exudate becomes purulent from any 
cause, which happens but rarely, the prognosis is much aggravated. If 
the patient has an active tuberculous lesion in the lung, the prognosis 
is very grave indeed. Recovery is exceptional. 

I have seen one case in which a serofibrinous effusion broke through 
a bronchus, overfilled the lung, and nearly suffocated the patient. It 
is noteworthy that no infection of the pleura took place. The patient 
recovered after expectorating the fluid from his chest. 

At times we observe that tuberculous pleurisy with effusion spreads 
to other serous membranes — the pericardium, the peritoneum, and 
finally to the meninges, Some authors hold that many cases of poly- 



448 TUBERCULOSIS OF THE PLEURA 

serositis are of tuberculous origin. A comparatively large proportion 
of patients show, as one of the terminal phenomena,, symptoms and 
signs of tuberculous peritonitis with ascites; meningitis also is rather 
common. In a recent study of this subject, P. Ameuille 1 has suggested 
that in such cases the infective agent may be a strain of tubercle bacilli 
which has special affinity for serous membranes. But this requires 
further proof. 

There remains yet to be mentioned that in very rare instances sudden 
death terminates a case of pleural effusion. The patient, without any 
premonitory symptoms, perceives agonizing pain in the pectoral region, 
severe dyspnea, becomes cyanosed, and dies. The causes which have 
been considered as operative in these cases are: Kinking of the vena 
cava in left-sided effusions; pressure on the right auricle in right-sided 
effusions; embolism of the pulmonary veins, or the brain, the result 
of thrombosis in the pulmonary vessels. But in many cases none of 
these and other suggested factors explained the sudden death. In 
extremely rare instances tapping, or even simple exploratory puncture, 
is followed by sudden death. 

Are All Pleurisies Tuberculous? — The most important prognostic 
problem in these cases is whether the patient, after recovering from his 
pleurisy, will develop pulmonary tuberculosis, and if so, what effect 
will the pleural lesion have on his immediate and ultimate outlook for 
recovery. Experience has taught that a large proportion of patients 
with pleurisy ultimately develop phthisis. But we also know many who 
have remained alive and well for many years, or for natural life. It is 
for these reasons that physicians warn their patients with pleurisy 
that it is not enough to treat the primary disease, but that it is abso- 
lutely imperative to take into consideration their chances of becoming 
phthisical. I know of many persons suffering because of this possibility 
which has been imparted to them by their physicians; they feel as if 
the sword of Damocles is hanging over their heads. 

It is therefore important to be able to single out the patients who are 
likely to become tuberculous ultimately, and those who are not. This 
we are not able to do in every instance, but there are indications which 
clearly show us the way in a large proportion of cases. The tuberculous 
nature of pleurisy may be determined by the following considerations : 

1. Tubercle bacilli may be found in the exudate removed with an 
aspirating syringe or by tapping. 

2. The symptoms presented by the patient during the pleural 
disease, as well as soon after recovery. 

Tubercle Bacilli in the Pleural Exudate. — Tubercle bacilli are only 
rarely demonstrated microscopically in pleural exudates. Even in 
cases of pronounced tubercle, the fluid is frequently sterile, and in many 
cases in which microorganisms are found, it is usually the germs of 
pneumococci, staphylococci, streptococci, etc. Thus, Ehrlich found 

1 Ann. de med., 1917, iv.on. 






PROGNOSIS IN TUBERCULOUS PLEURISY 449 

tubercle bacilli in pleural exudates only in 2 out of 22 cases; Longa and 
Pensunti, in 1 out of 22 ; Jakowski in 1 out of 32 ; Fernet, in 3 out of 20 ; 
Thue, in 1 out of 30; Weber, in 1 out of 23; Landouzy and Queryat 
found them only once in their extensive experience. Netter, 1 collating 
these figures, shows that in a total of 415 cases of serofibrinous pleurisy 
he found an average of 2 per cent, in which tubercle bacilli could be 
demonstrated in the exudate microscopically. In my own cases, it is 
extremely rare to find them. 

But it appears that the negative outcome of microscopic examina- 
tion of the exudate does not exclude the possibility of tuberculosis as a 
cause of the pleurisy. The fact that in cases with pronounced and 
advanced tuberculous lesions in the lungs no bacilli are found in the 
fluid, shows that there are some factors which either destroy the bacilli 
within the fluid, or interfere with their staining proclivities. Even 
though it has been my impression that many pleural effusions compli- 
cating pulmonary tuberculosis are caused by pyogenic microorganisms, 
or pneumococci, as is attested during epidemics occurring in hospitals 
for consumptives, yet a larger proportion than 2 per cent, is undoubt- 
edly due primarily to tubercle bacilli. 

Attempts at culturing the fluid on proper media have also failed to 
show the presence of tubercle bacilli in the majority of specimens of 
fluid examined. Similar unsatisfactory results have been obtained 
by inoculation experiments; only 10 to 20 per cent, of the pleural exu- 
dates inoculated into animals have proved positive, as can be seen from 
the extensive statistics gathered by Chantemesse and Courcoux. 2 
Even with improved methods the proportion of positive results has not 
been materially increased. It has namely been found that when a large 
quantity of the aspirated exudate is injected into a guinea-pig, it is 
more likely that the animal should become tuberculous than when a 
small quantity is injected. But even with the injection of 30 c.c. of 
the fluid, or its centrifuged sediment, the results more often turn out 
negative than positive. 

Only recently we have been gleaning some light on this intensely 
interesting, and also very practical, problem. In experimental tuber- 
culous pleurisy with effusion, tubercle bacilli are only rarely dis- 
covered. Robert C. Paterson 3 found that about two hours after 
inoculating the pleura of a guinea-pig very few, or no bacilli, either 
phagocyted or free, could be discovered in the effusion. He found, 
however, that these same effusions were virulent for, and actually 
infected, normal guinea-pigs in every case when inoculated subcuta- 
neously. The problem then arises, what becomes of the bacilli in the 
effusion? It seems that in other serous membranes the bacilli also 
disappear. Thus, it is very rare that tubercle bacilli are found in the 
ascitic fluid in peritoneal tuberculosis, and in cerebrospinal fluid in 

1 These de Paris, 1883; Bull. soc. de med. des hop. 1891, p. 176. 

2 Les pleuresies tuberculeuses, Paris, 1913, p. 12. 

3 Am. Rev. Tuberc.,1917, i, 353. 
29 



450 TUBERCULOSIS OF THE PLEURA 

tuberculous meningitis. Rist, Roland, and Kindberg 1 found most of 
their peritoneal inoculation experiments turned out negative, while 
Manwaring and Bronfenbrenner 2 observed that the bacilli disappeared 
from the peritoneal exudates in sensitized animals. The exudate of 
serous membranes is thus apparently bactericidal. 

It has also been suggested that the bacilli are too few in number to 
be found with ease in the fluid microscopically; that those which are 
present are enmeshed in flakes of fibrin. For this reason, large quanti- 
ties of the fluid, or better of the centrifuged sediment, may produce 
infection after inoculation, when small quantities fail. 

But after all, it seems that serous surfaces, excepting that of the 
meninges, react very favorably to infections, particularly with tubercle 
bacilli. Thus, tuberculous joints show strong tendencies to heal; so 
does the peritoneum. The same is true of the pleura. Most tuber- 
culous infections of that serous membrane lead but to dry pleurisy, 
or to small, insignificant effusions which are spontaneously and often 
quickly absorbed. Even in cases in which the entire pleura is involved 
in the process, the prognosis is good in nearly all cases, as was already 
shown (see p. 447). For this reason some authors have been inclined 
to attribute all the so-called primary pleurisies to an attenuated strain 
of tubercle bacilli. It is, however, the opinion of other writers, notably 
Koniger, that the attenuation in the virulence is due to the action of 
the exudate produced by the reacting pleura. Whether this is due 
especially to active antigens or antibodies, or to the very strong 
capacity of the pleura to absorb foreign material, cannot be stated 
with any degree of exactitude at present. This is a point which 
deserves further careful investigation. 

On the whole, it may be stated that irrespective of the cause, absence 
of tubercle bacilli from pleural exudates, as indicated by microscopic 
examination or inoculation experiments, by no means shows that the 
lesion in the pleura is of a non-tuberculous character. This is of 
immense clinical importance for obvious reasons. 

Clinical Facts about the Tuberculous Origin of Pleurisy. — For more 
than a century physicians have suspected that most of the inflam- 
matory processes in the pleura, when not due to another obvious cause, 
such as an intrathoracic neoplasm, or to cardiac or renal disease, are 
of tuberculous origin. Stoll, in the latter half of the eighteenth century, 
already considered latent pleurisy as tuberculous. Bayle said that 
"pleurisy is really not a cause, but an effect of tuberculosis." Laennec 
was very emphatic when referring to the tuberculous nature of pleurisy. 
"It is absurd," he said, "to believe that tuberculosis may terminate in 
pleurisy; the facts of pathological anatomy show that in the vast 
majority of cases tuberculosis may be latent for a certain time and 
cause no deviation from normal health, while in other cases pleurisy 
is but the first manifestation, often really the effect, of the presence of 
tubercle which existed within the body for some time." 

i Ann. de med., 1914, i, 312, 375, 2 Jour, Exper, Med., 1913, xviii,601. 



PROGNOSIS IN TUBERCULOUS PLEURISY 451 

Modern clinicians are inclined to the same view. In this country 
the first to collect a series of cases which have been under observation 
for a long period of time was Vincent Y. Bowditch 1 of Boston, who found 
that out of 90 cases of acute pleurisy which had been observed by his 
father and followed up by himself between 1849 and 1879, 32 died of, 
or had, phthisis. George G. Sears 2 collected the following figures from 
the literature: Of 451 cases of pleurisy, 176, or about 39 per cent., 
subsequently developed phthisis or other well-marked tuberculous 
affections. Barr 3 found that out of 57 cases of pleurisy between 1880 
and 1884, 21 had already died of some form of tuberculosis, mainly 
pulmonary phthisis, at the time his report was made (1890). Couston 
and Dubrull, 4 from army experience, say that all soldiers who have 
suffered from pleurisy are no longer fit for military duty, and that a 
majority die later from tuberculosis. William Osier 5 reports that 
among 86 cases in his wards in which the after-histories were studied 
by Dr. Hamman, 34.8 per cent, became tuberculous and died. In his 
Shattuck lecture 6 he reports that he had carefully analyzed the post- 
mortem records of his ward cases in which pleurisy — fibrinous, sero- 
fibrinous, hemorrhagic, or purulent — was found and the result was 
that 32 were definitely tuberculous. The after-histories of 130 cases of 
primary pleurisy with effusion reported by Hedges 7 showed that at 
least 40 per cent, died from or had tuberculosis within six years. 

The most extensive series of cases carefully analyzed were reported 
by Allard and Koster. 8 Allard deals with 200 cases of idiopathic pleu- 
risy treated from 1881 to 1893, their subsequent fate having been 
investigated in 1900. Koster deals with 371 cases of idiopathic pleurisy, 
and 62 of specific pleurisy, treated from 1894 to 1908, and reported in 
1910. They also made an analysis of 2123 cases of pulmonary tuber- 
culosis as to the frequency of pleurisy in their past history. The two 
series were compiled along the same lines, but independently of each 
other. In the first series, representing 180 cases of serous and 20 of 
dry pleurisy, it was found that 16 to 28 years later 87 patients were 
alive and well; 28 were tuberculous, 61 had died of tuberculosis and 24 
had died from other causes. In the second series, representing 334 
cases of serous, and 37 of dry pleurisy, it was found that 2 to 16 years 
later 164 were alive and well, 118 were tuberculous, 62 had died of 
tuberculosis, and 27 had died from other causes. Taking the two series 
together, the writers find that idiopathic serous pleurisy is followed 
sooner or later by pulmonary tuberculosis in 47.7 per cent, of cases, and 
that even in cases of idiopathic dry pleurisy the percentage is as high 
as 42. 

It has also been found that a rather high proportion of tuberculous 

1 Tr. Am. Climatol. Assn., 1889, vi, 1. 

2 Boston Med. and Surg. Jour., 1892, cxxvi, 192. 

3 British Med. Jour., 1890, ii, 1058. 4 Gaz. hebd. de med., 1886, xxiii, 662. 
5 British Med. Jour., 1904, ii, 999. 6 Tr. Massachusetts Med. Soc, 1893. 

7 St. Bartholomew's Hosp. Rep., 1900, xxxvi, 83. 

8 Hygeia, 1911, lxxiii, 1105, 



452 TUBERCULOSIS OF THE PLEURA 

patients have had pleurisy before the onset of their pulmonary disease. 
Thus Allard and Koster report that among 2123 cases of phthisis 650, 
or 30.6 per cent., gave a history of idiopathic pleurisy. E. A. Pierce 1 
analyzed two series of cases dating from 1905 until the time of his 
report. In the first series of 1767 cases of pulmonary tuberculosis, 614, 
or 35 per cent., gave a history of pleurisy. In the second series of 518 
cases, 52 per cent, gave a history of previous pleurisy. He adds that, 
including simple adhesions with other marked changes, pleurisy was 
found in 74.4 per cent, of 215 cases. 

Statistics like the above, indicating that from 30 to 40 per cent, of 
patients suffering from pleurisy subsequently develop phthisis, or that 
from one-third to more than one-half the tuberculous patients have 
had pleurisy before the onset of the pulmonary tuberculosis, abound 
in medical literature. But it appears that, not all clinicians have had 
the same experience; many report that, while pleurisy is often followed 
by phthisis, the proportion is not so high as the above statistics might 
lead us to suppose. Thus Blakiston 2 reports 53 cases which had 
remained well for several years; Austin Flint speaks of 47 cases with 
but 3 possible instances of subsequent tuberculosis. Out of 21 cases 
reported by J. P. Bramwell 3 only 3 died of tuberculous disease. 
Coriveaud 4 had but four deaths from this cause out of 27 cases, one of 
whom he had followed for twenty-five years and one for fifteen. 

That the menace of pleurisy, however significant, is not threatening 
every patient, is attested by the experience of physicians of long years 
in practice; they all have many patients who have had pleurisy, dry 
and with effusion, and remained well for years. To be sure, in hospital 
practice we encounter patients who have become tuberculous after 
pleurisy, but those who remain well do not come into hospitals. It is 
therefore important to bear in mind that, while a large proportion of 
cases of pleurisy is due to tubercle, not all is; in fact more than three- 
fifths the number of patients with pleurisy pass through life without 
developing phthisis', as the statistics cited indicate. The reasons for this 
are to be sought for in the following facts: (1) Many cases of pleurisy 
are due to microorganisms other than the tubercle bacillus, or alto- 
gether due to non-specific causes; (2) Even when due to the tubercle 
bacillus, the outlook is not so gloomy as some statistics seem to show. 

Non-specific Pleurisy. — Pleurisy may be produced experimentally 
by the injection of irritants into the pleural cavity, especially turpen- 
tine. Injuries to the chest also are often instrumental in producing 
pleurisy. Fractured ribs, and the calluses which are produced while they 
heal, are at times responsible for pleurisy which is clinically recurring 
producing symptoms at irregular intervals, just like dry pleurisy due to 
other causes. These may be considered aseptic pleurisies; though the 
ends of the fractured ribs, or the callus, may act as irritants and reduce 

1 Northwest Med., 1918, xvi, 79. 2 Quoted from Sears. . 

3 Edinburgh Med. Jour., 1889, ii, 909. 

4 Jour, de med. de Bordeaux, 1887-8, xvii, 601. 



PROGNOSIS OF TUBERCULOUS PLEURISY 453 

the vitality of the pleural tissue, thus favoring the localization of bac- 
teria brought there hematogenically. Still they cannot be considered 
specific. Similarly, pleurisy is very common in cases of cancer of the 
thoracic viscera, and in certain cases of cardiac and renal disease. 
Though these are not of an inflammatory character, yet they produce 
effusions. 

Among the pathogenic microorganisms, the tubercle bacillus is not 
alone holding the evil distinction of producing pleurisy Thus the meta- 
pneumonic pleurisies are very common, and those due to various 
strains of streptococci and staphylococci, which at times occur in epi- 
demics, cannot be considered ' tuberculous. I have been under the 
impression that the last-mentioned pathogenic agents are quite fre- 
quently responsible for pleurisy in tuberculous patients, occurring as it 
does occasionally almost epidemically in hospitals for consumptives. 
On the other hand, considering the wide distribution of tuberculosis in 
mankind, it is to be expected that many with dormant or latent 
tuberculous lesions should have them reactivated during or after 
attacks of pleurisy due to any cause. When judging statistics of this 
sort, this factor is to be borne in mind. 

Factors Influencing the Prognosis in Tuberculous Pleurisy. — It is 
a noteworthy fact, not appreciated to the extent it deserves, that when 
pleurisy is followed by tuberculosis, the outlook for the patient is not 
grave, as a rule. Thus, it has been noted for many years that pleurisy 
complicating active tuberculosis may be "beneficial;" it is often 
observed to arrest the tuberculous process in the lung, and the patient 
improves temporarily, or even recovers. At one time it was suggested 
that these pleurisies act beneficially by compressing and immobilizing 
the affected lung, thus affording it rest and an opportunity for the lesion 
to cicatrize, as we aim in doing when inducing pneumothorax for thera- 
peutic purposes. But further observation has shown that the mechani- 
cal factor is by no means the main one. It has been noted that in 
cases in Avhich the effusion is slight in amount, and only short in dura- 
tion, the effect on the lung may prove very salutary. In fact, in many 
cases of dry pleurisy followed by, or complicating phthisis, the tuber- 
culous process is mild, sluggish in its progress, and shows strong ten- 
dencies to heal. Thus Koniger 1 found among 49 cases of initial pleurisy, 
only 1 in whom the tuberculous process pursued a progressive course. 
Among 29 cases of secondary pleurisy complicating active tuberculosis, 
the disease was favorably influenced in 27 cases. It is noteworthy that 
during the course of initial pleurisy, observes Koniger, open tubercu- 
losis, with tubercle bacilli in the sputum, is extremely rare. Among 
78 cases he could find only 1 of this type, though in many, extensive 
changes in the lung could be made out, and they expectorated consider- 
able sputum. In my own experience also I recall but few cases of pri- 
mary pleurisy in which tubercle bacilli were detected in the sputum 

i Ztschr. f. Tuberk., 1911, xvii, 529. 



454 TUBERCULOSIS OF THE PLEURA 

microscopically. Furthermore, in tuberculous patients with extensive 
lesions in the lungs, with excavations which have rapidly formed, there 
is but rarely observed one who gives a history of pleurisy preceding 
the onset of phthisis. Of course, many adhesions may be found when 
these patients come to autopsy, but, as a rule, the pleural lesions had 
not manifested themselves by a reaction producing special symptoms. 
Acute progressive phthisis following primary pleurisy is extremely 
rare, excepting in acute miliary tuberculosis, or in acute pneumonic 
phthisis which, on rare occasions, is accompanied, or masked, by a 
pleural effusion (see p. 438). In our daily practice we meet with cases 
of chronic tuberculosis manifesting itself mainly by a thick pleura, in 
addition to the infiltration or excavation of the apex, living on for many 
years. Many of these are told that "one lung is completely gone" yet 
they live on, and may even be fairly active at their avocations, despite 
the activity of the tuberculous process in the lungs and pleura. Among 
these are the cases with dextrocardia, sinistrocardia, immobility of 
the diaphragm, etc., all due to massive pleural adhesions, in whom the 
prognosis as regards duration of life is much better than in those in 
whom the pleura shows no signs of having been implicated materially 
in the tuberculous process. 

The reasons for the salutary influence of pleurisy on the pulmonary 
tuberculous process are not definitely known. Only rarely is the 
mechanical factor instrumental because, as was stated above, dry 
pleurisy, as well as small effusions, often act in the same manner. The 
biochemical action of the exudate, or the inflammatory reaction of the 
pleura, may be the cause, as Koniger suggests, but so far we have no 
proof for this contention. At any rate, it seems to me that the salutary 
effect of pleurisy on the pulmonary process is due to the tendency it 
has to induce a productive inflammation. Fibrosis appears to be 
Nature's weapon against the destructive action of the tubercle bacillus. 
Other pathological processes characterized by fibrosis also have a good 
influence on tuberculosis, as is the case with gout, interstitial nephritis, 
some cases of tertiary syphilis, etc. (see p. 524). As to the substance 
which is effective in producing a proliferation of connective tissue 
during an attack of pleurisy, whether it is biochemical, or some specific 
antibody, we are in the dark. It is a subject which deserves further 
investigation. 

The prognosis in primary tuberculous pleurisy is thus not so gloomy 
as some would lead us to believe. The patient may be told that after 
the pleurisy has passed, his chances of developing phthisis are greater 
than in the average human being, still he is by no means invariably 
doomed. The majority pass through life without becoming phthisical. 
If he should be unfortunate and develop pulmonary tuberculosis, he 
may be told that his outlook is rather favorable. In most cases the 
disease pursues a mild, slow course and tends to recovery. 

Influence of Age on the Prognosis. — The prognosis is also greatly 
influenced by the age of the patient. Pleurisy with effusion in children 



PROGNOSIS OF TUBERCULOUS PLEURISY , 455 

is not followed by pulmonary tuberculosis, as a rule. In some bron- 
chiectasis remains for life, but the lesion is not tuberculous. From 
Allard and Koster's statistics it appears that the prognosis after idio- 
pathic pleurisy is much brighter in early than in middle life, and, while 
the subsequent incidence of tuberculosis is only 30 per cent, when the 
pleurisy had occurred between the ages of six and ten, it is as high as 
60.4 per cent, when the pleurisy has occurred between the ages of 
thirty-one and thirty-five years. At the high age of sixty-six to seventy 
idiopathic pleurisy is also followed by tuberculosis in 40 per cent, of all 
cases. It appears also that in tuberculosis following pleurisy, when it 
does occur in children, the prognosis is better than when it occurs in 
adults. The tendencies to recovery are more pronounced in children 
than in adults. 

Symptoms of Tuberculosis Following Pleurisy. — It is important to 
be able to single out the cases in which phthisis is likely to develop 
after an attack of pleurisy so as to institute timely treatment. We 
could then also permit those who are unlikely to become phthisical to 
pursue their life-work without fear lest their occupation will be instru- 
mental in promoting the onset of the disease. It is unfortunate that, 
while this problem confronts us very frequently, we are not always able 
to give definite information to the patients during the course of the 
pleural affection . In some, the pain in the chest, the fever, the cough, 
etc., disappear within a few days and we may be deceived by the 
prompt recovery. Within a few weeks, or months, fever, cough, 
expectoration, nightsweats, emaciation, etc., make their appearance, 
and signs of phthisis are discovered in the chest. In others, as I have 
observed in two cases, the recovery is complete and the patient returns 
to work, but several months later, without any assignable exciting 
cause, symptoms of tuberculous meningitis appear, and kill him 
promptly. In many with effusions the fluid is absorbed within a few 
weeks, but the patient keeps on ailing, coughs, expectorates, has mild 
fever and nightsweats, and remains anemic and debilitated; signs of 
a tuberculous lesion in the lungs may or may not be clearly evident. 

A patient with any form of pleurisy who does not recover his general 
health and well-being soon after the fever abates, or the effusion is 
absorbed, should be considered as probably tuberculous and a careful 
search should be made for physical signs of a tuberculous lesion in one 
of the apices. It must be emphasized, however, that in these cases the 
tuberculous lung lesion is almost invariably localized in one of the 
apices. When physical examination of the chest shows signs of a thick 
pleura exclusively over the base, where the pleural friction was audible, 
or the exudate had occurred, the chances of the lesion being tuber- 
culous are remote; these lesions usually turn out to be bronchiectatic 
and not tuberculous. When signs of a thick pleura, such as impaired 
resonance, feeble breath sounds and moist consonating rales found 
exclusively at the base, are due to tuberculosis, there is also to be 
made out a tuberculous lesion in the apex in nearly all cases. In doubt- 



456 TUBERCULOSIS OF THE PLEURA 

ful cases of this sort radiography may be of immense value in localizing 
an apical lesion. Of course, the sputum is to be examined repeatedly 
for tubercle bacilli. 

Patients who recover promptly after an attack of pleurisy may be 
pronounced as free from active tuberculosis at the time. But, as was 
already shown, they are more likely to develop phthisis in later years. 
It may be stated as a general iule that this predisposition wanes with 
the advance of time after the attack of pleurisy. Allard and Koster 
found from their extensive statistics that in the majority of cases 
which became tuberculous, to be precise in 85 per cent., the tuber- 
culous process flared up within five years after the attack of pleurisy. 
In younger individuals, however, it appears that pleurisy is followed 
by pulmonary tuberculosis much later. From these figures, as well as 
from daily observation, it appears that if the patient has completely 
recovered his health after an attack of pleurisy he should be told that 
while he may reengage in his vocation, he must be careful in his mode 
of life during the ensuing five years. 

A careful inquiry should be made into the past history of the patient. 
Many with so-called primary pleurisy have in fact presented symptoms 
of phthisis for months before the appearance of the pain in the chest or 
the symptoms and signs of an effusion, but they disregarded them, as 
has already been emphasized. In such cases the diagnosis of tuber- 
culosis may be safely made. It is in these cases that tubercle bacilli 
are frequently found in the sputum. 

Prognosis in Secondary Pleurisy. — In pleurisy developing during 
the course of pronounced phthisis the outlook depends mainly on the 
underlying disease, on the condition of the tuberculous lungs, as well 
as on the resisting powers of the patient. In unilateral tuberculous 
lesions, which show no tendency to progression, an attack of dry pleu- 
risy may have no effect on the ultimate outlook. It is likely to torture 
the patient by the pain in the chest and shoulder that it inflicts, and its 
likelihood to recurrence; but the prognosis as regards the duration of 
the disease may even be improved, as has already been mentioned. 
The same is true of aa effusion. In some cases I observed that it has 
been the turning-point for the better when, before the onset of the 
complication, the progress of the lung disease was active and pro- 
gressive. The effusion may be slow in disappearing, but when it is 
finally absorbed the patient feels well, even though he remains with a 
thick pleura and with signs of adhesions producing dyspnea on exertion. 

It is different with extensive bilateral lesions. While in some cases 
we may even here note improvement, in the majority the reverse is 
true. The effusion is apt to aggravate the cough, produce distressing 
dyspnea, and the fever rises higher. Hectic fever is not uncommon. 
At times the end comes suddenly through asystole, but in most cases 
the course is lingering. Repeated tappings are of little or no avail in 
many cases. In fact, it has been my impression that, very often, the 
prognosis is distinctly aggravated by tapping the exudate, excepting 



PROGNOSIS OF TUBERCULOUS PLEURISY 457 

when the effusion is very copious and produces menacing symptoms 
through its mechanical effects. 

Prognosis in Empyema. — Empyema is one of the most dangerous 
complications of phthisis. Spontaneous absorption hardly ever occurs. 
Operations for the removal of pus are very unsatisfactory. The result 
is usually that the fever, cachexia, and amyloid degeneration of the 
viscera carry off the patient sooner or later. I have seen a few cases of 
empyema in which the pus found its way into a bronchus and was 
expectorated. The patients were "cured" of the empyema, but the 
tuberculous process proceeded on its course to a fatal termination. 

In general it may be stated that the vast majority of empyemata in 
tuberculous subjects are in truth cases of pyopneumothorax, and the 
prognosis is the same as in the latter condition (see p. 444). 

Another mode of termination of empyema remains yet to be men- 
tioned. While in rare cases repeated tapping may finally clear the 
pleura of the purulent exudate, in still rarer instances it has been 
observed that the pus is spontaneously absorbed and the patient re- 
mains with a thick pleura, pulmonary retraction, dilatation of the 
bronchi, and deformities of the chest and spine. In very rare cases 
the abscess in the pleural cavity becomes encapsulated and the patient 
may go around for many years without considerable inconvenience. 
The pus in these cases changes in appearance, becoming milky-white, 
or ivory in color, as in chylothorax, and is in fact converted into 
cholestrin. In one case, with a history of pleurisy twelve years before 
he came under my observation, I withdrew with an exploratory syringe 
yellowish -white fluid, which, on microscopic examination, showed an 
abundance of cholestrin crystals. In another case the woman, forty- 
five years of age, had a very pronounced kyphoscoliosis, the result of an 
empyema, during childhood. Finding signs suggestive of a pleural 
effusion, I inserted an exploratory needle and withdrew milky fluid 
which microscopically was found studded with cholesterin crystals. 






CHAPTER XXVII. 
PNEUMOTHORAX. 

This is the most frightful complication of pulmonary tuberculosis. 
It is of more significance than copious pulmonary hemorrhage because 
the latter only terrifies the patient, and its ultimate prognosis is usually 
favorable, as we have already shown, but pneumothorax is deadly, 
and the victim is justified in his apprehension that the collapse, and 
agonizing dyspnea, are indications that he is breathing his last. From 
West's statistics it appears that 70 per cent, of patients attacked by 
pneumothorax die, and in phthisis the proportion is even higher. 

The frequency of pleural adhesions in patients with pulmonary 
phthisis explains why all suffering from this disease do not develop 
pneumothorax. Eugene L. Opie, 1 making autopsies, found that nearly 
half of the focal tuberculous lesions are situated immediately below the 
pleural surface. It is not uncommon to find a calcified nodule immedi- 
ately below the puckered pleura and about it upon the adjacent pleura 
a group of small nodules. Fibrous adhesions usually bind together the 
adjacent pleural surfaces. It is thus clear that if there were no adhe- 
sions, pneumothorax would be the most common complication of 
pulmonary tuberculosis. 

Spontaneous Pneumothorax. — Many authors have applied this term 
to cases in which rupture of the pleura and entry of air into its 
cavity have occurred in an apparently healthy individual who has not 
known of any premonitory symptoms, nor of an acute onset, and who 
develops no subsequent hydrothorax or pyothorax. Indeed, I have 
had patients coming into my office complaining of breathlessness and 
an examination disclosed the presence of pulmonary collapse and air 
in the pleura. In most of these patients the air is absorbed within 
three to six weeks. In one case under my care an effusion developed, 
but it remained sterile and was absorbed spontaneously. Nikolski 2 
collected from literature 66 cases of this kind and he found that 59 
recovered completely within eight weeks, and 3 within four months. 
But there have been reported chronic and persistent cases. Bittorf 3 
mentions a case lasting twenty-five years and Whitney 4 one of seven 
years' duration. 

The origin of this form of pneumothorax has been discussed by many 
medical writers. The consensus of opinion appears to be that they 



Jour. Exper. Med., 1917, xxv, 855. 
Ueber den spontanen Pneumothorj 
Munchen. med. Wchnschr., 1908, '. 
4 Philadelphia Med. and Surg. Jour., 1886, cvx, 397. 



2 Ueber den spontanen Pneumothorax, Inaug. Dis. Giessen, 1912. 

3 Munchen. med. Wchnschr., 1908, lv, 2274. 



Spontaneous pneumothorax 450 

are all due to tuberculous lesions of the lungs or pleura. Hamman 1 
agrees with those who hold that the commonest cause is a pleural ad- 
hesion of a tuberculous character tugging upon the visceral pleura and 
producing a rent. The fact that no infection of the pleura occurs shows 
that the rent occurs about the adhesions, and not over the seat of the 
parenchymatous lesion. Indeed, Flint, Letulle, and West have reported 
cases in which only a single subpleural tuberculous nodule was found 
to have ruptured and permitted air to enter the pleural cavity. That 
the rent need not be very large to produce this effect is evident from 
the fact that surgeons, while anesthetizing the brachial plexus with 
cocaine, have produced pneumothorax through a puncture with the 
hypodermic needle. Schepelmann and A. Viscber have reported such 
cases. Similarly, pneumothorax is in rare instances produced while 
performing paracentesis for exploratory purposes. 

While in the vast majority of cases the occurrence of this form of 
pneumothorax is an indication that there is a pulmonary tuberculous 
lesion, there are exceptions. There is considerable evidence that spon- 
taneous pneumothorax may occur as a result of rupture of emphyse- 
matous blebs or bullae. Zahn, 2 Bach, 3 and many others have described 
such cases, and they speak of pneumothorax due to pleural rupture 
without inflammation. It may also be caused by rupture of inter- 
stitial emphysematous blebs, the air entering the interstitial tissues 
and reaching the visceral pleura, forming a vesicle which ruptures. We 
often see this mechanism in cases in which therapeutic pneumothorax 
has been induced. During the recent epidemic of influenza I met 
with a case which could only thus be explained. 

Spontaneous pneumothorax occurs more frequently in males than in 
females. Xikolski found it in 75 males to 14 females; Fussell and 
Riesman, 4 45 and 10, respectively. Over-exertion, cough, etc., are said 
to be the usual exciting causes, but at times no cause can be discov- 
ered. 

In most of the patients the air in the pleura is absorbed within a 
shorter or longer time and they recover completely. In some, the 
recovery is but temporary, and within a few months or years there 
appear symptoms and signs of a pulmonary tuberculous lesion. In 
rare cases there have been observed recurrent attacks of spontaneous 
pneumothorax. Gabb, Vitvitski, Sale, Clyde L. Cummer, 5 and others 
reported such cases. In one case eleven recurrent attacks were observed. 
On the whole the prognosis is very good indeed. In fact, in 2 cases 
under my care, there was a history of indefinite symptoms of pulmonary 
tuberculosis for some time before the occurrence of pneumothorax. 
But the collapse of the lung was apparently of the kind called "provi- 
dential" by some writers. After the air in the pleura was absorbed, 
the patient felt well. One has thus kept well for six years. 

1 Am. Jour. Med. Sc, 1916, cli, 229. - Virchows Archiv, 1891, cxxii, 197. 

3 Brauer's Beitrage, 1910, xviii, 21. 4 Am. Jour. Med. Sc, 1902, cli, 229. 

6 Am. Jour. Med. Sc. 1915, cl, 222. 



460 PNEUMOTHORAX 

Pneumothorax During the Course of Phthisis. — As a complication 
of phthisis, pneumothorax is of graver significance than when occurring 
in apparently healthy individuals. The frequency of this complication 
varies with the character of the clinical material. It is not very fre- 
quent in hospitals for advanced cases because only patients with old 
lesions, in whom pleural adhesions prevent its occurrence, are admitted. 
According to Powell, about 6 per cent, of fatal cases of phthisis at the 
Brompton Hospital at London succumbed with pneumothorax; Wil- 
liams found 10 per cent., and Weil even 13 per cent. On the other hand, 
Biach, among 715 tuberculous cases, found only 0.73 per cent, compli- 
cating pneumothorax; Blumberg, among 425 cases, 3.1 per cent.; 
Drasche, among 26,231 cases, 1.46 per cent. 

As was just stated, these wide differences in the proportion of compli- 
cating pneumothorax are to be ascribed to the differences in the 
material. In many hospitals for consumptives we meet with cases of 
sudden death during the night. Some of these are due to sudden pro- 
fuse internal hemorrhages, but in most cases the cause is pneumothorax; 
which killed the patients before aid could be summoned. 

The lesion is more likely to occur in the left than in the right pleura. 
From a collection of 234 cases reported by Louis, Walshe, West, and 
himself, Powell finds that in 95 the rent was in the right and in 139 
in the left pleura. He attributes it to the greater frequency with 
which the left lung becomes the seat of tuberculous disease. 

Symptoms. — The onset is sudden, unexpected. The patient has 
known that he is tuberculous for some time, and may have been assured 
that his prospects for an ultimate recovery are good. But suddenly, 
like a thunderbolt out of a clear sky, after a fit of coughing, some slight 
exertion, or without any exciting cause at all, he is seized with a sharp 
agonizing pain in the chest, he feels as if "something has given way/' 
or as if something cold is trickling down his side. He at once sits up 
in bed holding his hand fast over the affected side, gasping for breath. 
iVcute distressing dyspnea, cyanosis, a small, rapid and feeble pulse, 
cold, clammy extremities and other phenomena of collapse soon make 
their appearance. The facial expression is that of profound agony, 
the eyes prominent, the lips livid, and the forehead clammy. The 
respirations are frequent — fifty or more per minute, and superficial. 
The temperature, which may have been elevated for some time, 
suddenly drops to below normal and the cough, which may have been 
annoying before the accident occurred, ceases for a time; perhaps 
because of the pain the patient restrains himself. 

In very acute cases the patient may expire within a few hours as a 
result of profound shock, dyspnea, and heart failure. Many of the 
cases of sudden death in phthisis are due to this cause. But in most 
cases the circulation adapts itself by degrees to the altered conditions 
of the thoracic viscera, the dyspnea is ameliorated, the temperature 
rises to above normal, and the patient feels somewhat relieved, the air- 
hunger not being so acute as at the onset, though he still breathes 






PNEUMOTHORAX DURIXG THE COURSE OF PHTHISIS 461 

forty or more times per minute, and is still cyanosed. Within a few 
days, usually between the third and fifteenth day, an effusion of fluid 
into the affected pleura is found, hydropneumothorax, or pyopneumo- 
thorax. 

The size of the perforation into the lung has but little influence on 
the acuity of the distress— a small opening the size of a pinhead may 
permit the entry of sufficient air into the pleura to collapse the lung 
completely and to displace the thoracic and abdominal organs just as 
well as a larger one. In fact, in some quickly fatal cases only a small 
opening, or slit, is found at autopsy, while in others, with large openings, 
little distress is seen, healing is rapid, and the patient may last for 
months. At the necropsy it is found that the opening is usually small, 
linear, slit-like ; and occasionally circular, at times attaining the size 
of a dime. In some cases there are two or even three perforations. 

Mechanism of Pneumothorax. — It is of clinical significance whether the 
perforation closes speedily and no more air or pus can pass into the 
pleural cavity, thus allowing absorption of the air. The symptoms, 
prognosis, and treatment depend mainly on this point. There are 
described in text-books three varieties of pneumothorax — open, closed, 
and valvular. In the open variety there is a patent opening which 
permits air to pass in and out of the pleural cavity, and the tension 
within the affected pleura is equal to that of the external air. In the 
closed variety the perforation has healed, and the air in the pleural 
cavity may be absorbed sooner or later, as is the case with induced 
therapeutic pneumothorax, with or without the development of an 
effusion which is generally serous. In the valvular variety, during 
inspiration or cough air enters freely into the pleura, but is prevented 
from coming out again during expiration by a valve or contraction 
of the slit. The result is that the tension within the pleural cavity 
becomes very high and, pushing the mediastinum to the opposite 
unaffected side, causes distressing dyspnea, cyanosis, and heart failure, 
till the patient is no longer able to cope with the situation and succumbs. 

This interpretation of pneumothorax has of late been questioned by 
West, Bard, C. P. Emerson, Castaigne, and others. West says: "All 
pneumothorax is at first valvular, at any rate more or less, i. e., the air 
finds more or less difficulty on expiration. Thus the pleura becomes 
more and more full of air and the lungs more and more compressed, and 
this obviously tends to close the hole more or less completely. When 
the hole is of ordinary size, it will become patent on inspiration and thus 
admit air, but only so long as the pressure in the pleura is less than 
that of the air in the air tubes. As soon as the pressure on the two sides 
is equal, no more air can enter, and the hole remains closed. If the 
edges cohere, the hole will remain permanently closed; if not, as soon 
as the pressure in the pleura is diminished, as it may be by paracentesis, 
the orifice may open again into the pleura. This is the explanation in 
many cases of the return of dyspnea after paracentesis." 

It should also be mentioned that the acute and distressing symptoms 



462 PNEUMOTHORAX 

observed in pneumothorax are not necessarily due to high pressure 
within the pleura. It has been stated that when the intrapleural pres- 
sure reaches 6 to 10 cm. of water, dangerous symptoms are bound to 
ensue. But that this is not a fact has been learned recently through 
experiences with therapeutic pneumothorax. Much higher pressure 
within the pleural cavity is often produced, over 20 cm. of water, 
without producing acute and menacing symptoms. Actual measure- 
ments have shown that with a pressure of 15, 18, 25, and Bernard even 
raised it exceptionally to 35 or 45 cm. of water, the only effect was 
that the mediastinum was displaced to the opposite side, but the 
circulation adapted itself, and the patient felt quite comfortable, at 
least during rest. The writer has repeatedly observed that when fluid 
appears in an artificial pneumothorax, the pressure within the pleural 
cavity rose to 25 or 30 cm. of water, yet the distressing and menacing 
dyspnea of spontaneous pneumothorax was lacking. 

The accommodative powers of the pleural cavity have been studied 
by Emerson. 1 He found that the chest, by elevation of the ribs and 
descent of the diaphragm, can accommodate various quantities of fluid 
without any change of pressure. If fluid is continuously injected into 
the pleural space, the pressure, of course, must rise, but it tends to do 
so in stages or jerks, owing to attempts on the part of the chest to 
accommodate itself to the increase and so keep down the pressure. He 
ascribes this to a special reflex mechanism. 

As has been pointed out by Sir R. Douglass Powell, the displace- 
ment of the mediastinum is not necessarily due to the pressure exerted 
by the air in the pleural cavity. His manometric measurements have 
revealed no positive pressure in pneumothorax. From his investi- 
gations he is inclined to believe that the dislocation of the heart is 
due to the unopposed traction exerted by the elastic unaffected lung. 
Because they are no longer held up by the elasticity of the lung, the 
diaphragm and the abdominal viscera sink downward. 

Clinically this view is confirmed by the fact that tapping a pneumo- 
thorax is not always effective in relieving the patient for any dura- 
tion of time. In fact, better results are now obtained by, instead of 
tapping the pleura, insufflation of more gas (see p. 716). The recent 
experimental investigations of Evarts A. Graham and Richard D. Bell 2 
of the Empyema Commission of the United States Army tend to con- 
firm this view of the mechanism of pneumothorax. 

Partial Pneumothorax. — In old chronic cases of phthisis we meet with 
partial pneumothorax in which there is a perforation into the pleural 
cavity, but owing to dense adhesions the air is only filling up a limited 
pouch, at a place where the pleural sheets are not adherent. The onset 
is less acute and the symptoms of collapse are usually absent. The 
patient may have some pain in the chest, dyspnea, etc., but these 
attract little attention in a disease like phthisis in which these symp- 

1 Johns Hopkins Hosp. Rep., 1903, ii, 1. 

2 Am. Jour. Med. Sc, 1918, clvi, 839. 






PNEUMOTHORAX DURING THE COURSE OF PHTHISIS 463 

toms are so frequent without the occurrence of pneumothorax. Careful 
physical examination may disclose signs of the condition, but it is 
easier to find it out with the aid of skiagraphy. The writer 1 has 
reported cases in which skiagraphy could not decide. It is often mis- 
taken for a large cavity, especially when it is localized over an apex, 
but even in the lower parts of the chest it may exquisitely simulate 
pulmonary excavation. 

Latent Pneumothorax. — At times we meet in tuberculous patients a 
pneumothorax without a history of an acute onset with pain, dyspnea, 
collapse, etc. In some of these cases careful inquiry elicits a history 
pointing to a subacute onset, but such symptoms are quite common 
in chronic phthisis without this complication. In one case admitted 
to the hospital we found complete collapse of the lung and we at first 
suspected an artificial pneumothorax, produced before admission, but 
it turned out to be a latent case. Several cases of this type have pre- 
sented themselves for examination at my office. No history of onset 
could be elicited, yet the pleural cavity was full of air and the lung 
collapsed. 

In chronic phthisis we also meet with cases in which there is a 
sudden onset with all the symptoms of this accident, but physical 
examination fails to reveal any of the signs. The French call it pneu- 
mothorax muet, the mute form. In these cases the signs do appear, 
however, within a few days. In one of my cases of this character a 
radiographic plate showed that the air was filling the thoracic cavity 
for an inch or two along the axillary line. In others there was an 
interlobar air pouch. These forms are best diagnosticated with the 
.T-rays. 

Double Pneumothorax. — Double pneumothorax has been met with 
in phthisis on exceedingly rare occasions. On Plate XX is shown the 
radiogram of a case that came under the writer's observation. It is 
incompatible with life. But D. Hellin 2 and R. Staehelin 3 mention cases 
which lasted for days. 

Physical Signs. — The affected side of the chest is larger — in the 
maximum inspiratory position; the shoulder raised, the intercostal 
spaces obliterated, tense and tender to the touch. While the number 
of respirations is fifty or more per minute, movements of the thorax 
are seen only in the unaffected side, while the affected side is fixed, 
almost immobile. In the vast majority of cases the apex beat cannot 
be seen, but when visible it is found at the left axillary line in right- 
sided pneumothorax and at the xyphoid cartilage, or even beyond 
it, in left-sided perforations. Vocal fremitus is abolished over the 
affected side. 

Instead of the dull note which was found before the accident, the 
affected side emits a hyperresonant, sometimes a tympanitic note, 

1 Arch. Int. Med., 1917, xx, 739. 

2 Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1907, xvii, 414. 

3 Mohr and Staehelin's Handbueh der inneren Medizin, Berlin, 1914, ii, 756, 



464 PNEUMOTHORAX 

depending on the tension of the air within the pleural cavity. By 
comparison, the unaffected side appears to emit a defective or dull 
note. In cases in which the upper part of the pleura is adherent and 
does not collapse, the apex is dull or "boxy" on percussion. When 
later fluid makes its appearance in the pleural cavity, we elicit a flat note 
over the lower part of the chest and the flatness changes its level with 
the change in the patient's position (see Figs. 1, 2 and 3, Plate XX). 
Shifting dulness is pathognomonic of air and fluid in the pleural cavity. 
Displacement of the thoracic and abdominal viscera can be made out 
more or less easily by percussion. In right-sided lesions the liver dul- 
ness disappears altogether, or is displaced downward, and the heart is 
shifted to the left, even as far as the axillary line; in left-sided pneumo- 
thorax the heart dulness may be completely absent, or displaced to the 
right, and the splenic dulness may also be absent. In fact, the spleen 
and the liver may be felt distinctly low in the abdomen. The displace- 
ment of the heart may be noted a few minutes after the occurrence of 
the accident. 

We may also elicit various metallic or amphoric notes on percussion, 
especially with a coin placed over the chest and tapping it with a stick 
or pencil, while listening with the naked ear or stethoscope over the 
opposite side of the chest. A thimble over the middle finger may be 
used percussing over the nail of the ring finger placed on the chest wall. 
The metallic sound heard while listening on the chest is exquisite. 
This method has the 'advantage that no assistance is needed to bring 
out the so-called coin, or penny sound. Biermer's and Wintrich's 
signs, as well as cracked-pot resonance, may be elicited in many cases. 

Auscultation shows complete absence of breath sounds over the 
affected side of the chest in cases in which the opening is small or 
closed and the lung is completely collapsed. When the upper parts of 
the pleura are adherent, the auscultatory phenomena of the original 
lung lesion are audible, but below no sounds at all are heard. But in 
most cases there are heard amphoric breath sounds at some point 
between the shoulder-blades. Exceptionally we meet with a case of 
pneumothorax in which the voice and breath sounds are audible in an 
exaggerated form all over the affected side. When the opening into 
the lung is large, permitting the passage of air from the bronchi into 
the pleural cavity, we may hear an exquisite variety of amphoric 
breathing, or metallic sounds, which are characteristic. The voice 
sounds, as well as the cough, may also have a metallic echo. 

The splashing or succussion sound is audible at a distance in many 
cases, and the patients themselves are annoyed by it. Some patients 
know how to jerk their bodies to produce it to the best advantage. 
I have had patients in whom the succussion sound was the only indica- 
tion of fluid in the thorax, all other signs being absent because of the 
depression of the diaphragm, the result of the pressure exerted by the 
tension of the air in the pleura. It is an excellent proof of the existence 
of air and fluid in the pleura. It is stated that it may be elicited in 



PLATE XVIII 



Fig. 1 



Fig. 2 





Dense infiltration of the upper half of 
the left lung with displacement of the 
heart to the left. Right lung emphyse- 
matous. 



From same patient as Fig. 1. Spon- 
taneous pneumothorax, air filling left 
pleural cavity, and displacing the heart 
to the right. 



Fig. 3 



Fig. 4 





Pneumothorax in right pleura extending 
in a thin layer of air from the diaphragm 
to the apex. Right lung slightly collapsed 
and presents consolidation at its lower 
third. The rest appears studded with 
cavities and calcified nodules. Lower 
half of left lung emphysematous; upper 
half nodular infiltration, especially at 
axilla. Heart and trachea displaced to 
the right. 



Hydropneumothorax in the right pleura. 



PLATE XIX 



Fig. 1 



Fig. 2 





Left pleura filled with air, but large 
cavity with dense walls under second and 
third interspace did not collapse. Nodular 
infiltrations throughout right lung. Di- 
lated bronchi and enlarged glands in hilus 
region. 



Complete pneumothorax of right 
thoracic cavity pushing mediastinum to 
the left and compressing the left lung. 
Trachea visible as markedlv displaced to 

left. 



Fig. 3 



Fig. 4 













Old fibroid phthisis with extensive 
involvement of the left lung and pleura. 
Spontaneous pneumothorax of right pleura. 



Diffuse tuberculous process all over 
both lungs; marked, peribronchial infil- 
trations, and calcified glands along the 
hilus. The apex is infiltrated and adherent 
in the left side; below the clavicle there is 
a circumscribed pneumothorax, which on 
physical exploration gave signs of a cavity. 
The lower half of the left pleura is thick- 
ened, which cannot be differentiated in 
the radiogram from fluid. 



PLATE XX 



Fig. 1 



Fig. 2 





Hydropneumothorax in left pleura. Pa- 
tient in erect position. 



Same patient as in Fig. 1, but body lean- 
ing to the right. 



Fig. 3 



Fig. 4 





Hydropneumothorax. Patient lying on 
the side. 



Double pneumothorax. 



Illustrating Shifting Fluid in Hydropneumothorax. 



PNEUMOTHORAX DURING THE COURSE OF PHTHISIS 465 

the stomach and colon, but I have not met with a case in which this 
vitiated a diagnosis. 

Metallic Tinkling.— A clear musical note, heard at intervals on listen- 
ing over a hydropneumothorax, resembling a drop of water falling into 
a reverberating vessel, may be heard in some cases. At times it is 
only heard after cough. It is apparently not due to the falling of a 
drop at all, but to a rale produced in some portion of the lung which 
acquires a metallic character by reverberation. 

Diagnosis. — The diagnosis of pneumothorax has undergone quite 
some changes within recent years since we have had an opportunity 
to study this condition produced artificially in tuberculous patients 
for therapeutic purposes, and also since we employ skiagraphy for the 
purpose of examining the chest. We now have explanations for some 
phenomena which were formerly obscure, and we know that certain 
signs formerly considered pathognomonic of pneumothorax, are not at 
all invariable accompaniments of the disease. 

In the usual case of pneumothorax during the course of phthisis the 
sudden onset of urgent dyspnea, pain in the chest, collapse, etc., 
coupled with physical signs of pulmonary collapse, suffice to establish 
the diagnosis. But there are many sources of error. We may have 
pneumothorax without any of these acute symptoms, as has been 
already stated. In fact, since the x-rays have been employed the 
number of latent and mute cases of pneumothorax has enormously 
increased. On the other hand, we meet in phthisis cases of acute 
dyspnea, pain, and even collapse not due to this accident. On several 
occasions paroxysmal tachycardia in hysterical female patients has 
simulated pneumothorax to a marked degree. Especially difficult are 
the cases of localized pneumothorax, because the mediastinum is not 
displaced, and a thickened pleura may obscure the tympany, and the 
absent, or amphoric, breath sounds may be otherwise interpreted. At 
times it is very difficult to differentiate a partial pneumothorax from a 
large pulmonary cavity, and before the advent of skiagraphy mistakes 
of this kind were more frequently made than at present. The differ- 
entiation is usually of practical value, because the prognosis in cases 
with large excavations is very unfavorable, while with a localized 
pneumothorax it is more hopeful. 

Even in cases with complete collapse of the lung, tympany may not 
be elicited on percussion, as we have learned lately in cases of artificial 
pneumothorax. It appears that it all depends on the tension of the 
air within the pleural cavity. In hydropneumothorax, tympany is 
found when there is but little fluid and considerable air; but when 
the effusion is copious we get flatness which disappears when the fluid 
is aspirated, provided the pleura is not too thick. 

The position of the heart is usually of assistance in deciding whether 

we deal with a large cavity or a pneumothorax: In the former it is 

displaced toward the affected side, while in the latter it is moved 

away from it. But even here there are many important exceptions, 

30 



466 PNEUMOTHORAX 

owing to previous pleural adhesions, etc. Skiagraphy usually decides, 
but not always. 

The signs obtained on auscultation differ very much in cases of open, 
as compared with closed pneumothorax, and in the latter cases it 
depends on whether the lung is completely or only partially collapsed. 
A closed pneumothorax with complete collapse is mute; no breath 
sounds at all are audible, as a rule. At times we perceive some bronchial 
breathing in the interscapular space emitted from the bronchi near 
the spine. In the open variety we usually hear amphoric breathing of 
an exquisite type. In many cases of phthisis, in which the pleura is 
free all over, it is adherent at its upper third, over the site of the main 
lesion, and does not collapse at that place, and we obtain the breath 
sounds and rales peculiar to the diseased lung. 

The breath-sounds often audible over a completely collapsed lung 
were formerly attributed to some opening into a bronchus, allowing 
air to pass in and out of the pleura. We now know that this is not 
always the case because in artificial pneumothorax, where an opening 
into the lung is positively excluded, we often perceive the same acoustic 
phenomena. It seems that the air in the pleural cavity is capable 
of transmitting the sounds in the bronchi when in a certain condition 
of tension. 

The bell sound is almost invariably heard in all cases in which the 
effusion is not too thick, as in some cases of pyopneumothorax. It 
is easily elicited by placing a coin over the anterior surface of the 
thorax and percussing it with another while auscultating posteriorly 
or in the axilla. A clear, ringing, bell-like sound, which is character- 
istic, is heard. But exceptionally it is also heard over large cavities, 
or even a dilated stomach. It is often absent in pneumothorax; but 
when heard it is of significance, showing, as it does, air and fluid in the 
pleural cavity. We may hear it only with the patient in the horizontal 
position. In some it appears only after some of the fluid has been 
aspirated. 

A positive diagnosis of pneumothorax can be made when one is 
alert and looks for it in every suspicious case. In most cases the 
abrupt onset of the urgent symptoms and the physical signs suffice. 
In doubtful cases the roentgen rays decide easily and speedily. 

A rare complication of pneumothorax, the spontaneous as well 
as the artificial varieties, is pneumopericardium — air entering the 
pericardial sac. We then have instead of the cardiac dulness, hyper- 
resonance or tympany, sometimes cracked-pot sound. On ausculta- 
tion we hear that the heart sounds are extraordinarily intensified, and 
a splashing sound is audible, or a succussion sound, synchronous with 
the systole. In the case observed by the author there was also a* 
metallic tinkle and a friction fremitus, especially when the patient bent 
his body forward. Similar cases have been reported by Wenckebach, 1 

1 Ztschr. f. klin. Med., 1910, Ixxi, 402, 



PNEUMOTHORAX DURING THE COURSE OF PHTHISIS 467 

Cowan, 1 Harrington and Riddell, and Alfred Meyer. 2 With the aid 
of skiagraphy the diagnosis offers no difficulty. 

Radiography. — The arrays have their greatest field of usefulness in 
our attempts at discerning the changes in the thoracic organs when the 
lung is collapsed by air in the pleural cavity, especially in the localized 
variety of pneumothorax, which formerly escaped attention in most 
instances. Complete pneumothorax is clearly seen on the fluoroscopic 
screen or the skiagraphic plate. The affected hemithorax shows a 
very bright area, lacking in lung markings; in contrast with the 
opposite expanded lung it may be said to be brilliant. The collapsed 
lung is seen lying near the mediastinum, or against the spinal column, 
as a dark band (see Fig. 4, Plate XVII). During respiratory efforts 
the collapsed lung becomes somewhat larger and brighter. In many 
cases of tuberculous pneumothorax some part of the lungs, especially 
the apex, is retained in its position by adhesions. 

The mediastinal organs are, in most instances, displaced toward the 
unaffected side. In many cases we may note rhythmic movements of 
the mediastinum, especially the heart; during inspiration the medi- 
astinum is moved toward the unaffected side. The dome of the 
diaphragm is lower than that of the opposite side; its convexity is 
gone, and an almost straight line may be made out running downward 
and outward. The intercostal spaces are wider, and the ribs, as well as 
the diaphragrn, move less during respiration than those of the unaf- 
fected side. In some there is complete immobility of the affected half 
of the thorax. In some cases the paradoxical phenomena in the dia- 
phragmatic motion, first described by Kienboch, may be noted. In- 
stead of the normal, simultaneous contraction of the two halves of the 
diaphragm during each inspiration when they descend like two pistons, 
there is observed a dissociation of this movement. The two sides of 
the diaphragm behave like two sides of a balance: While the unaf- 
fected half descends, the affected half rises into the thoracic cavity. 

When fluid appears in a pneumothorax it is easily discerned with the 
.T-rays. It is, however, important that the examination should be made 
with the patient in the erect posture, otherwise the fluid may spread 
out all over the chest and thus escape notice by those who have little 
experience with these cases. The fluid sinks down, and is seen. as a 
deep shadow occupying the lower part of the chest, while the upper 
part, just above the level of the fluid, is bright. It has been well com- 
pared with a bottle half-filled with ink. The line of demarcation 
between the fluid below and the air above is sharply drawn, which is 
in contrast with effusions in pleurisy in which the dark shadow of the 
fluid merges by degrees into the bright lung tissue above. Inclining 
the patient to the side will shift the level of the fluid (see Figs. 1,2, and 
3, Plate XX). In some cases shaking the patient may show agitation 
of the fluid within the chest, showing the mechanism of succussion. 

1 Quarterly Jour. Med., 1914, vii, 165. 
* Medical Record, 1915, Ixxxviii, 991. 



468 PNEUMOTHORAX 

Localized Pneumothorax. — As has already been stated, the diagnosis 
of localized pneumothorax is at times important owing to the difference 
in the outlook for the patient : The prognosis is good in many cases of 
localized pneumothorax, while it is poor in those with large pulmonary 
excavations. In our attempts at this differentiation we should bear in 
mind the following points: 

The history of the onset is most important in nearly all doubtful 
cases. A pulmonary cavity of large dimensions does not appear sud- 
denly, while signs of a localized pneumothorax appear within a few 
minutes. If we have had the patient under observation for some time, 
the sudden appearance of signs of excavation, such as tympany, 
amphoric breathing, and pectoriloquy over a circumscribed area, should 
suggest pneumothorax. In most patients we find that there has been 
a sudden change for the worse, even in such as have been doing quite 
well. A sharp, stabbing pain in one side of the chest is felt, followed 
by dyspnea, cyanosis, prostration of variable degrees, etc. But we 
meet with many cases in which the history is negative. 

While in some cases a localized pneumothorax may prove fatal within 
a short time, in most the acute symptoms abate within a few days, 
the pain disappears, the dyspnea is ameliorated, though the patient 
remains short-winded on slight exertion. 

Physical exploration of the chest shows that in localized pneumo- 
thorax the cavity is, as a rule, "dry," no adventitious sounds are 
audible; while large excavations usually show large, moist, consonating 
rales and gurgles. A large, "dry" cavity, especially when extending to 
the axilla, should not be accepted as such without careful investigation. 
The breath sounds in pneumothorax are distinctly amphoric or metallic; 
such exquisite metallic sounds are exceedingly rare in cavities. In the 
former a metallic tinkle may be heard, which is exceedingly rare in the 
latter. In cavities bronchophony is the rule, and whispered pectorilo- 
quy is frequently absent, while in localized pneumothorax the latter is 
commonly present and is strikingly pronounced, clear, and articulate, 
usually perceived as if spoken directly into the stethoscope, a phe- 
nomenon exceedingly rare in pulmonary excavations, in which only 
the spoken voice is transmitted. The whispered echo is also more 
frequently heard in pneumothorax. Moreover, in localized pneumo- 
thorax, especially the interlobar variety, whispered pectoriloquy is 
distinctly or exclusively heard high up in the axilla, which is very rare 
in cases with excavations. On inspection retraction of the chest wall 
is characteristic of large cavities, while bulging may be found, though 
rarely, in cases of localized pneumothorax. The location of the medi- 
astinal organs gives no reliable criteria as to the condition. They are 
almost invariably displaced toward the affected side in large cavities, 
but the adhesions which are instrumental in localizing the pneumo- 
thorax may also keep these organs in the place they had been before 
the rent in the pleura had occurred . 

The roentgenographic findings are invaluable in most doubtful cases. 



LOCALIZED PNEUMOTHORAX 469 

A bright, circumscribed area, lacking in lung markings, when not 
surroimded by a thick, dark shadow, is pathognomonic of a localized 
pneumothorax. But at times eyen this is deceptive. The air pouch 
may be located anteriorly, while posteriorly is adherent lung tissue 
which screens it, and no bright area appears on the roentgenogram, as 
I have seen in some cases. On the other hand, the walls of the pul- 
monary cavity may not cast a shadow on the roentgenogram, and as a 
result we may find on the plate a picture clearly showing a pneumo- 
thorax, while the real lesion is a large pulmonary cavity. Such anoma- 
lous findings at necropsy have been reported by many clinicians and 
roentgenographers. The writer 1 has reported cases showing localized 
pneumothorax distinctly on the x-ray plate, yet the autopsy showed a 
large cavity in the lung. It seems to me that in such doubtful cases 
fluoroscopy is of more value than roentgenography. In localized 
pneumothorax we often see the mediastinum rhythmically moving 
during the respiratory act; during inspiration it is moved toward the 
affected side. This is best seen in artificial pneumothorax, after the 
first one or two fillings, when there is but a small air pouch in the pleura. 
In the spontaneous variety, when the adhesions are not dense enough 
to hold the mediastinum very fast, we may observe the same phe- 
nomenon, and this is never seen in cases of large cavities. In most 
cases it is, however, easy to differentiate on the roentgenogram between 
cavities and localized pneumothorax. In extensive disease, pulmonary 
cavities are usually multiple; they contain not only air, but also 
secretions which are not constant in quantity, changing intermittently, 
and bridges made up of connective tissue and bloodvessels. No clear, 
bright area lacking in lung markings is, as a rule, produced on the 
roentgenogram; their margins are more opaque and the pulmonary 
tissue around them is denser than in localized pneumothorax. Bearing 
these points in mind, we may differentiate the two conditions in most 
doubtful cases. In some, as we have shown, this is impossible. 

Prognosis. — On the whole, the prognosis in spontaneous pneumo- 
thorax during the course of pulmonary tuberculosis is decidedly gloomy. 
Occurring, as it does, in patients who are already doomed because of the 
condition of the lungs, this accident but accelerates the inevitable. 
In very acute cases the patients succumb within a few days, and 90 
per cent, die within a month. An open pneumothorax, permitting the 
entry of the contents of pulmonary cavities into the pleura, is almost 
invariably fatal, sooner or later. 

While there have been reported cases of hydro- and pyopneumo- 
thorax that have survived for years, and some in whom the fluid has 
been absorbed, they are exceedingly rare, and in all cases of pyopneu- 
mothorax that I have seen the patients have succumbed within one 
year after the onset of this complication. 

Conditions are somewhat different in cases with closed pneumo- 

i Arch. Int. Med., 1917, xx, 739. 



470 PNEUMOTHORAX 

thorax, and also in the localized forms of this condition. They usually 
occur in patients with slight lesions and with good resisting power. 
So long as there is no communication with a tuberculous cavity, and the 
pleura is not infected, as is the case with artificial pneumothorax, the 
air in the pleura may in time be absorbed. In fact, it was these rare 
cases of collapse of the lung, and the resulting amelioration of the 
symptoms of phthisis, which suggested the idea of therapeutic pneumo- 
thorax. 



CHAPTER XXVIII. 

DIFFERENTIAL DIAGNOSIS OF PULMONARY 
TUBERCULOSIS. 

Speaking of the diagnosis of pulmonary tuberculosis, some assume 
that it is only important to differentiate the disease in its early or 
incipient stage, while when the lesion is more or less advanced the 
nature of the ailment is so clear that anybody, even of the laity, may 
make a diagnosis. That this is not the fact is clear when we contem- 
plate the relatively large proportion of non-tuberculous cases admitted 
to and at times kept for long periods in hospitals for advanced con- 
sumptives. Thus, J. Earle Ash 1 found that among the 198 autopsies 
that have been performed at the Boston Consumptives' Hospital since 
its foundation, 23 cases, or 11.5 per cent., proved to be non-tuberculous 
in so far, at least, that no active tuberculous lesion could be discovered. 
That this is not a unique condition is shown by other figures reported 
by Ash. He inquired in other hospitals for advanced tuberculous 
patients in this country and obtained facts about 353 autopsies, 
among which 38, or 10.8 per cent., were found non-tuberculous. Into 
my service at the Montefiore Hospital there are very frequently sent 
in patients who had spent many months, or even years, in various 
sanatoriums and hospitals for consumptives, but a careful clinical 
study of their cases shows that they present no signs of active tubercu- 
losis in any stage or form, and other diseases are diagnosticated, at 
times confirmed by autopsy. 

The number of incipient cases of tuberculosis which, on careful 
study, prove to be non-tuberculous, is undoubtedly higher. The fact 
that sanatoriums have a large proportion of "sputum negative" 
patients, some as high as 50 per cent., testifies strongly in favor of this 
view. When we bear in mind that hardly more than 10 per cent, of 
"sputum negative" cases — in which the sputum was examined several 
times and revealed no tubercle bacilli — are actually tuberculous, it is 
clear that many other clinical conditions pass for tuberculosis very 
frequently. This has been clearly demonstrated recently in the 
European armies, in which, at the beginning of the struggle, tens of 
thousands had been rejected by the draft officers and from army 
hospitals, but a careful examination showed that hardly one-third of 
these were really tuberculous. To be more exact, of 1000 men sus- 
pected of being tuberculous in the French Army, only 1.5 per cent. 
proved to be actually tuberculous, according to Kindberg and Del- 

1 Jour. Am. Med. Assn., 1915, hriv, 11. 



472 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

herm. 1 Eduard Rist 2 reports that in 1000 men sent back to a base 
hospital as suffering from pulmonary tuberculosis, only in 193 was the 
diagnosis confirmed by a careful study of the cases. In the rest many 
other diseases of the lungs, bronchi, and especially the rhinopharynx, 
were found. 

The sufferings inflicted on the patients, their relatives and friends 
by a diagnosis of tuberculosis, and the stigma it imposes on them, 
perhaps for life, as well as the economic loss sustained by the indi- 
vidual patient and the community, by such a diagnosis should make 
us hesitate before pronouncing a case tuberculous. But this can only 
be done when we have a clear appreciation of the pathological condi- 
tions which are likely to be mistaken for tuberculosis. In the following 
pages will be enumerated and discussed those disease conditions which, 
in the experience of the writer, are most commonly mistaken for 
phthisis. 

Diseases of the Upper Respiratory Passages. — In the author's 
experience, the most common pathological conditions mistaken for 
tuberculosis are diseases of the upper respiratory passages. A large 
proportion of the " suspects," as well as of the "incipient cases with 
negative sputum," treated in tuberculosis clinics, and often admitted 
to sanatorium s where they may be kept for an indefinite time, have 
no discoverable lesions of any kind in the lungs, bronchi, or trachea. 
Their main troubles are located in some part of the throat, the tonsils, 
the pharynx, or one of the nasal sinuses. Many have been operated 
upon for these conditions one or more times. These patients often 
cough, expectorate mucopurulent material, at times streaked with 
blood, etc. During some intercurrent affection, or a subacute exacer- 
bation of the rhinopharyngeal trouble, they may have some fever, 
anorexia, lose in weight and strength, etc. Streaky sputum at this 
time is sufficient incentive for a thorough examination. If some 
impaired resonance is found in one of the apices — and the right apex 
is very frequently deficient in air content in these cases — a diagnosis 
of tuberculosis is made, or at least the patient is placed in the category 
of the "suspects." Fastidious physicians find in these cases not only 
impairment of resonance in one of the apices, but also some clicks, or 
rales provoked by cough, and, perhaps, some prolongation of the 
expiratory murmur, or even bronchovesicular breath sounds. How- 
ever, repeated examinations of the sputum fail to reveal the presence 
of tubercle bacilli. But this does not deter some physicians from 
making it a case of tuberculosis with negative sputum; some examining 
physicians for sanatorium s pronounce them tuberculous and admit 
them to institutions. 

In children these chronic nasopharyngeal conditions, especially 
adenoids and enlarged tonsils, are even more often responsible for the 
erroneous diagnosis of tuberculosis, or of tracheobronchial adenitis, 

1 Presse Med., 1917, xxv, 645. 

2 Jour. Am. Med. Assn., 1917, lxix, 1266. 



DISEASES OF THE UPPER RESPIRATORY PASSAGES 473 

because they do not thrive, have mild fever, sweat at the least exertion, 
or at night when retiring to bed, etc. In fact, in many of these children 
impairment of resonance may be found in one of the interscapular 
spaces. 

The differential diagnosis of these nasal conditions from tuberculosis 
is based on one principle which is very important to bear in mind. 
Tuberculous disease, when active, is accompanied by symptoms of tox- 
emia, particularly fever and tachycardia. At least the temperature and 
pulse are unstable (see pp. 181, 239). While a slight rise in the tempera- 
ture may, at times, be discovered in the patients with adenoids, hyper- 
trophied tonsils, etc. (see p. 398), it is very uncommon. But the pulse- 
rate is hardly ever affected in these cases. The cough in rhinopharyn- 
geal disease differs markedly from that of incipient phthisis in most 
cases. The phthisical subject states that he had never coughed until 
the onset of the disease, while the patient with rhinopharyngitis has 
coughed for years, rather mildly hawking up every morning some 
tenacious sputum, at times streaked with blood, especially during an 
acute exacerbation; he has been "subject to colds." An examination 
of the nose and throat usually reveals the source of the trouble — 
enlarged tonsils, adenoid vegetations in the pharynx, hypertrophied 
turbinates, chronic sinusitis, atrophic rhinitis, etc. There may also 
be found some varicosities on the posterior wall of the pharynx, tongue, 
or trachea (see p. 210) which are the source of the blood in the sputum. 

The mistake of pronouncing these patients tuberculous may be 
avoided in the vast majority of cases by adhering to the following 
guiding diagnostic principles: No patient should be pronounced sick 
uith active phthisis unless there are found distinct signs of an apical 
lesion, with positive sputum, when the pulse and temperature are normal, 
when he states that he has been "subject to colds' for many years, and 
shows signs of pathological changes in the nose or throat. Only consti- 
tutional symptoms of phthisis, such as fever, tachycardia, languor, loss 
of flesh, etc., and tubercle bacilli in the sputum, justify a diagnosis 
of tuberculosis when the physical signs of a lesion in the lung are lacking 
or are indefinite. It is, at times, advisable to send these patients to 
the country for a few weeks' vacation and it will be found that they 
improve very rapidly, cease coughing, and gain in weight and strength. 

Children with enlarged tonsils or adenoids often show marked rises 
in temperature every afternoon. Some of the temperature curves of 
these little patients are not unlike those obtained in tuberculous cases. 
But we must bear in mind that while subacute and chronic disturbances 
in the throat are common in children, pulmonary tuberculosis is rare 
(see p. 396). Moreover, the temperature in children is unstable, and 
liable to fluctuations not observed in adults (see p. 398) . It is therefore 
imperative that these factors should be taken into consideration before 
pronouncing a child tuberculous and perhaps rob it of an education. 
In children of school age tuberculosis should be diagnosed only when 
there are definite and clear-cut signs of a lung lesion, especially when the 



474 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

symptoms may be explained as due to evident pathological changes in 
the nose and throat. Tuberculous tracheobronchial adenitis, on the 
other hand, is quite common among these children, but the prognosis is 
much better than is generally appreciated (see p. 412). 

Collapse Induration of the Apex.: — In many persons who have been 
troubled with nasal obstruction for years, certain changes occur in the 
apex of the lung, especially the right, which gives physical signs often 
closely simulating those of tuberculous lesions in the apex of the lung. 

The symmetry of the two apices is not always perfect, nor do they 
always have the same resonance and breath sounds in most of appar- 
ently healthy people. In many the differences are so striking as to 
attract attention, and when cough, expectoration, fever, etc., occur 
for any reason, a diagnosis of tuberculosis is apt to be made based 
upon the asymmetrical findings over the upper part of the chest. In 
persons suffering from adenoids, enlarged tonsils, or other nasal or 
pharyngeal obstruction, collapse of the parenchyma of the right apex 
is often met with; the air within the alveoli is resorbed, and the lung 
tissue becomes indurated, greatly simulating conditions in phthisical 
lesions. Kronig 1 was the first to describe these cases in detail, and 
after him many other writers have reported that it is one of the most 
common respiratory disorders mistaken for phthisis. Many of the 
negative sputum cases in sanatoriums belong to this class. 

It is a purely local, non-specific induration of the lung apex showing 
physical signs exquisitely simulating those of phthisis. The following 
points of differentiation may be of value: Patients with collapse 
induration have been sufferers from nasal obstruction since childhood, 
and generally have enlarged turbinated bones, adenoids, or hyper- 
trophied tonsils. They complain that they have not been able to 
breathe properly through the nose for years, have expectorated con- 
siderably, suffered from dryness and itching of the throat, and have 
had a strong tendency to colds, tonsillitis, and frequent bronchial 
catarrh. The classical facies of the mouth breather is often observed 
in these patients — open mouth, enlarged and drooping lips, oblitera- 
tion of the nasolabial fold, etc. In tuberculosis ail these are lacking. 
The sputum shows distinct evidences that it is derived from the upper 
respiratory tract: It is watery, mixed with saliva, and colorless; 
sometimes containing gray or bluish globules, not unlike the kind seen 
in pneumonokoniosis. Microscopically there are often found epithelial 
cells from the mouth, nose and throat, but no tubercle bacilli nor 
elastic tissue. 

Again it must be emphasized that the toxemia of tuberculosis is not 
observed in these cases. The pulse and temperature are normal, and 
the nutrition of the patient remains good, excepting during an acute 
exacerbation of the rhinopharyngeal conditions. The general appear- 
ance of the patient is good. Despite the fact that he has been coughing 

1 Deutsche Klinik, 1907, xi, 634. 



CHRONIC PNEUMONIC PROCESSES 475 

for many months or years, he appears well nourished and does not 
lose in weight, as is usual in active tuberculosis. He is able to keep at 
his work efficiently, and the sense of fatigue and languor characteristic 
of phthisis is lacking. 

Apical Catarrh. — Most of us have been warned against the term 
apical catarrh of a non-tuberculous nature as something which does 
not exist and should be banished from medical terminology. But it 
appears that during recent years the profession is again acknowledging 
that there is often to be seen a catarrhal condition of one or both apices 
which is not caused by tubercle bacilli. This is especially to be observed 
in persons who have symptoms and signs of pulmonary emphysema, 
and those working at dusty trades. They often show all kinds of rales 
when their apices are auscultated, due to local bronchitis or tracheitis. 
There may be some hoarseness during the morning hours, due to the 
accumulation of secretions upon the vocal cords, which disappears 
during the day. The difficulty of differentiating these cases from tuber- 
culosis, especially fibroid phthisis, are often immense. In my wards 
at the Montefiore Hospital we must, at times, keep these patients for 
weeks, and examine the sputum many times before we can make up 
our minds as to the true nature of the trouble. In nearly all cases 
there is to be observed impaired resonance over one or both apices, 
but it is to be distinguished from dulness due to tuberculosis by the 
fact that there is no apical retraction — the resonance above the clavicle 
usually remains clear, while below the clavicle dulness is elicited as 
far as the second or third interspace. This is a sign which should 
always be looked for. 

The symptoms of tuberculous toxemia are also lacking; there is no 
elevation of the temperature nor acceleration of the pulse, excepting 
in the later stages of the pulmonary emphysema, when there are signs 
of dilatation of the right heart, The blood-pressure also is often high, 
while in phthisis it is low. 

Apical catarrh also often remains after attacks of influenza. Here 
the onset suggests an acute exacerbation of a tuberculous process, 
and the physical signs, combined with the cardinal symptoms, cough, 
debility, anemia, etc., are very often misleading. But no tubercle 
bacilli can be discovered, while the constitutional symptoms, fever, 
tachycardia, etc., are lacking; in fact, after an attack of true influenza 
the pulse is, as a rule, slow. The prompt recovery of the general 
health within a few weeks proves that the catarrh is of non-tuberculous 
origin. Here again we may get a clue by noting that there are no signs 
of apical retraction, the resonance above the clavicle is normal, and 
Kronig's field is not contracted in catarrh, while in tuberculosis it 
usually is. In some cases prolonged observation is required before a 
positive diagnosis can be made. 

Chronic Pneumonic Processes. — Cases which simulate tuberculosis 
to a degree as to prove baffling are those caused by pulmonary infec- 
tion with various cocci. In some only observation for many weeks 



476 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

will clear up the diagnosis. The first to make a careful study of these 
pulmonary infections was Finkler, 1 who found that they are mainly 
due to various types of streptococci. Recently many others have 
published extensive clinical and bacteriological studies and have shed 
considerable light on some of the obscure phases of this condition. 
From the studies of David Riesnian, 2 William Charles White, 3 Louis 
Hamman and S. YVolman, 4 A. H. Garvin, 5 J. L. Miller, and many 
others, it appears that we do not deal here with a single distinct 
pathological process, but that many varieties of infections of the lungs, 
bronchi, and pleura are classified under this term; the only thing they 
have hi common is that they very frequently simulate pulmonary 
tuberculosis and are treated as such. 

From the clinical standpoint there are two groups to be distinguished 
— the acute and the chronic types. The writer, at times, has had great 
difficulty in recognizing those running an acute course, while those 
of the chronic type, if seen some time after the onset of the disease, are 
very easily differentiated from pulmonary tuberculosis, usually during 
a single examination. 

The acute cases give a history of a sudden onset with fever, malaise, 
cough, and pain in some part of the chest. Those that follow influ- 
enza have expectorated more or less blood. Examination at that time 
shows no changes in the motion nor the resonance of the chest, but 
on auscultation feeble, rarely bronchovesicular, breath sounds and 
moist rales are audible over the greater part of one lobe, usually the 
lower lobe of the left lung. The apex is only rarely affected, and when 
this is the case the diagnosis is extremely difficult. Those who believe 
that in many tuberculous cases the lower lobes are affected at the onset 
of the disease will at once diagnosticate phthisis when finding signs 
of a localized lesion in one of the lower lobes. But, although there is 
more or less profuse expectoration of mucopurulent material, no 
tubercle bacilli can be discovered. On the other hand, all kinds of 
streptococci and diplococci may be easily demonstrated in every case. 
The fever abates within a week or two, but the physical signs, as well 
as the cough and expectoration, persist for three or four months, and 
finally even these disappear, leaving the patient in excellent physical 
condition. 

The differentiation of these cases from phthisis is made first by 
taking cognizance of the location of the lesion: Basal lesions in tuber- 
culous patients are extremely rare; when they do occur they are ter- 
minal phenomena, when the diagnosis is beyond question. A lesion 
at the base, while the apex is free, should be considered non-tuberculous 
unless the sputum is positive as regards tubercle bacilli. Adhering to 
this diagnostic principle we may avoid nearly all chances of a mistake 

1 Infektion der Lungen durch Streptokokken und Influenzabazillen, Bonn, 1895. 

; Am. Jour. Med. 3c, 1913, cxlvi, 313. 

3 Tr. Nat. Assn. for Study and Prev. Tuberc, 1915, xi, 140. 

-Ibid., 1916, xii. 170. 

; Am. Review of Tuberc, 1917, i, 1. 



CHROXIC PNEUMONIC PROCESSES 477 

of this kind. In the rare cases showing involvement of the upper lobe, 
it will be noted that while the auscultatory phenomena are pronounced, 
weak, or broncho vesicular breath sounds and showers of rales, localized 
and persistent in one apex, percussion yields a resonant, often a slightly 
tympanitic note. In phthisis such a discordance between the findings 
on auscultation and percussion is extremely rare. When such a large 
area of the upper lobe is implicated by a tuberculous process there is 
almost invariably dulness to be elicited above and below the clavicle. 
Similarly the .r-ray findings are, as a rule, negative in non-tuberculous 
infections of the lung. 

The chronic cases usually give a history of an acute or subacute 
onset. Many of them are, in fact, recurrences of the original acute 
process. The patient coughs, expectorates more or less sputum, has 
pain in the chest, and physical examination shows a distinctly localized 
lesion in one of the lower lobes of the lung, more commonly the left. 
However, in addition to the fact that the lesion is at the base, thus 
showing that it is unlikely to be tuberculous, there are other clinical 
features which tend to show that we are not dealing with tuberculosis. 
Tuberculosis with such extensive involvement is invariably accom- 
panied by symptoms of toxemia, fever, night sweats, emaciation, etc., 
while in the non-tuberculous cases all this is lacking. The tempera- 
ture is normal, or only slightly elevated some days, and the nutrition 
of the patient is good. He may be gaining in weight despite the per- 
sistence of the signs of an extensive lung lesion. The pulse is normal 
and stable, a point which should always be looked for in these cases. 
The low blood-pressure characteristic of phthisis is lacking. Some 
of these patients, despite the evidence of moisture within the lung, 
expectorate very little, while others expectorate considerably. Per- 
cussion has been of assistance in some cases. When there is no 
thickened pleura, and this is the case in the majority, the note elicited 
is resonant, and the .r-ray findings may also prove negative, while in 
phthisis with such extensive involvement the reverse is invariably 
true. 

Repeated examinations of the sputum give negative results as 
regards tubercle bacilli, but pneumococci, or any of the various strains 
of streptococci, are to be found in nearly every case. 

These cases are seen in patients of all age periods. They are very 
frequent in children of school age, and because of the erroneous state- 
ment in many books that the lesion in tuberculous children is most 
commonly found in the lower lobe, and that negative sputum is the 
rule, many physicians do not hesitate to diagnosticate tuberculosis in 
these little patients. But it is worth repeating that chronic tuberculosis 
of the lungs in children of school age, ichen it does occur, affects the upper 
lobe almost invariably, and lesions in the lower lobes should not be con- 
sidered tuberculous unless there are symptoms of toxemia and positive 
sputum. 

The course of these non -tuberculous lung infections is variable. 



478 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

Some recover within a few months and no trace of the trouble can be 
found. In others, the acute or subacute symptoms recur at irregular 
intervals, especially after acute " colds" or "grippe" during the winter 
and autumn months. A large number find their way into sanatorium s, 
where they remain for months. -I have many patients of this class 
who have taken several "cures" in institutions, and they still show 
signs of an old lung lesion at one base; they still cough and expectorate, 
though their general health has been, and is, excellent. Although they 
have been told that they are sputum-negative cases, a fact which they 
hardly ever fail to mention, they will not be convinced that their 
trouble is not of a tuberculous nature. 

Chronic Bronchitis and Bronchiectasis. — The average case of chronic 
bronchitis is easily differentiated from pulmonary tuberculosis when 
the following points are borne in mind: Barring those in whom the 
disease is secondary to cardiac or renal disease, and the diagnosis of 
the primary pathological process is clear, those suffering from bron- 
chitis have been subject to colds, have coughed and expectorated for 
many years, perhaps since childhood, and their general health has 
suffered but little, or not at all, as a result of these symptoms. On the 
other hand, phthisical subjects give a definite history of an onset, be 
it ever so insidious, when they began to cough, have fever, languor, 
nightsweats, anorexia, emaciation, etc., symptoms which lack in 
chronic bronchitis. We should not be rash in making a diagnosis of 
tuberculosis in a person who has coughed for many years and his general 
health has not suffered much, unless the signs and symptoms are clear-cut 
or the sputum is positive. In chronic bronchitis the harsh bronchial or 
bronchovesicular breath sounds, if present, are found diffused all over 
the chest, while in tuberculosis they are localized in only one or in both 
apices. Similarly the adventitious sounds, especially the moist rales, 
in phthisis are found in the upper lobes, while in bronchitis they are 
audible over the bases, on both sides of the chest. Despite the fact 
that the physical signs denote extensive involvement, the general 
condition of the patient leaves little to be desired, which is never 
observed in phthisis implicating the lower lobes of the lungs. Tuber- 
culous with basal lesions are hectic, marasmic, and soon moribund; 
they usually have laryngeal and intestinal complications. In tuber- 
culosis with such profuse expectoration tubercle bacilli and elastic 
tissue are almost invariably found in the sputum, while in bronchitis 
repeated examinations prove negative. 

Many patients who have been attacked by epidemic influenza with 
complicating pneumonia remain with chronic or subacute bronchitis 
for months, and because of the tradition that influenza is an activator 
of tuberculosis, they are treated as phthisical. During the recent 
epidemic many such cases have come under the writer's care. It is, 
however, to be noted that the impairment of resonance and the numer- 
ous large, moist consonating rales are audible, as a rule, over the bases ; 
that the pulse is normal or rather slow; that the general health is good; 



CHRONIC BRONCHITIS AND BRONCHIECTASIS 479 

in fact, the patients may be gaining in weight despite the extensive 
pulmonary lesion. The sputum is negative as regards tubercle bacilli, 
which hardly ever occurs in tuberculous subjects expectorating such 
large quantities. When these points are borne in mind errors can be 
avoided in nearly all cases. 

Bronchiectasis. — Bronchiectasis is not so easily differentiated, and 
many patients with this disease pass through life considered tuber- 
culous. Here we have a localized lesion in the chest exquisitely 
simulating chronic tuberculosis. In fact, many find their way into 
sanatoriums or hospitals for advanced consumptives, where they are 
kept for months and years. I have known numerous bronchiectatics 
who have been admitted to several sanatoriums as far advanced cases 
with negative sputum. In New York City many are kept under 
supervision by the authorities, and followed up to their places of 
employment with a view of preventing the spread of tuberculosis. 

Bronchiectatic patients give a history of long duration; they have 
coughed and expectorated for many years, perhaps since an attack 
of pneumonia or pleurisy; others since a surgical operation, during 
which general anesthesia was administered, and they began to cough 
soon after regaining consciousness. They state that while they almost 
always expectorate, the cough tortures them only periodically, with 
frequent remissions of shorter or longer duration, during which they 
do not cough much, but still expectorate "mouthfuls" without any 
effort. Posture, as a rule, has an influence on their cough and expec- 
toration; some cough and expectorate more when lying on the right 
side, while others do so when reclining on the left side. In some the 
sputum is fetid, while in most it differs but little from that brought 
out by advanced tuberculous patients. "While the majority of bron- 
chiectatics are afebrile, in many careful thermometry reveals low fever, 
99.5° F. to 101° F. in the afternoon. But the subnormal temperature 
in the morning characteristic of phthisis is usually absent in these 
cases. The pulse is normal, excepting during the advanced stages, 
when there is cardiac dilatation with tachycardia, dyspnea, cyanosis, 
etc. The blood-pressure is normal or high, and only rarely low, as is 
the case in phthisis. A large proportion of these patients spit blood; 
I have seen many in whom the pulmonary hemorrhage was copious 
and even fatal. 

It is thus seen that bronchiectasis may easily be mistaken for tuber- 
culosis. The differentiation is made along the following lines: In 
phthisis tubercle bacilli and elastic tissue are almost invariably found 
when the sputum is so profuse. Such large, active tuberculous cavities 
are found in patients with fever, cachexia, etc., and often laryngeal and 
intestinal complications are seen; these are all lacking in bronchiec- 
tasis. The tuberculous patient with excavations gives a history of an 
onset, insidious or acute, with fever, nightsweats, etc., while the 
bronchiectatic has coughed for many years, during which he has not 
shown any decided symptoms of tuberculous toxemia, and has retained 



480 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

a good general condition of health; he may even be quite adipose 
despite cough and expectoration. The physical examination, in the 
vast majority of cases, decides the diagnosis when we bear in mind the 
following points: 

In phthisis the lesion is nearly always localized in the apex or the 
upper lobe, in bronchiectasis in the lower or middle lobe, most com- 
monly in the left side of the chest, and exceptionally in the upper lobe. 
In phthisis signs of pulmonary retraction are almost invariably found — 
deep excavation of the supra- and infraclavicular fossse; in bron- 
chiectasis these are often fuller than normal. Dulness, when at all 
discovered by percussion, is found over the upper lobe in phthisis and 
over the lower lobe posteriorly in bronchiectasis. In the latter, more 
often than in phthisis, the resonance will be influenced by the presence 
or absence of secretions in the cavities — one day when they are full of 
secretions the note will be dull, while another, after the patient has 
expectorated profusely, it may be resonant, despite the fact that there 
are numerous large moist rales. In the uncommon cases of bronchiec- 
tasis of the upper lobe there is elicited resonance above the clavicle and 
dulness below it; the reverse is almost invariable in phthisis. With large 
tuberculous cavities in one lung there are almost always signs of implica- 
tion of the other side of the chest, while bronchiectasis is commonly 
unilateral. If the case has been kept under observation for a long time 
it will be noted that in tuberculosis signs of consolidation precede 
those of excavation, while in bronchiectasis the reverse generally 
occurs. Bronchiectatic cavities remain of about the same size for many 
years, often indefinitely, while active tuberculous cavities, with large, 
moist rales, show a decided tendency to enlarge. When bronchiectatic 
cavities involve both sides of the chest, which is very rare, thev r are 
found irregularly scattered, while phthisical cavities are contiguous 
extensions of the original apical lesion. It is, in fact, very rare to find 
in phthisical chests signs of more than one cavity with more or less 
healthy lung tissue between the two excavations. In multiple bron- 
chiectasis this is the rule. The heart is found displaced in both phthisis 
and bronchiectasis toward the affected side, but there is one significant 
difference which has been pointed out by William Ewart: "The dis- 
placement of the heart toward the diseased side in the chest in the 
usual cases of unilateral phthisis follows an oblique direction upward; a 
hoiizontal displacement is exceptional and suggests some complicating 
pleural factor. In unilateral bronchiectasis the displacement is, prac- 
tically speaking, always horizontal; not only by reason of the basic 
origin of the disease, but largely also owing to the lowering of the 
diaphragm on the sound side, with extension of the cardiac beat into 
the epigastric notch." This holds true in the vast majority of cases, 
and is most easily determined with the aid of the arrays. 

Another important distinction is to be mentioned : In bronchiectasis 
we may find bronchial breathing and a large number of large, moist, 
consonating rales and the a>rays show only slight opacities, variable, 



PLEURAL VOMICM 481 

according to the fulness or emptiness of the cavities at the time the 
examination is made. In phthisical cavities the x-ray findings are 
more accentuated and more extensive than physical signs would lead 
us to suppose. Scoliosis is a common sign of bronchiectasis — the 
convexity is turned toward the affected side; this is rare in cases with 
phthisical cavities. 

Pleural Vomicae. — Among the non-tuberculous pulmonary conditions 
treated as advanced consumption, and often sent in to my wards at 
the Montefiore Hospital, are pleural vomicae — localized collections of 
pus in the pleural cavity, originating in the lung, pleura, or even the 
abdominal organs, but burrowing their way to the exterior through a 
bronchus or fistula. These vomicae may be found anywhere in the 
chest, but they are most commonly located in the region of the inter- 
lobar fissure, and at the diaphragmatic pleura. 

The differential diagnosis between pleural vomicae and advanced 
phthisis is very simple in the vast majority of cases. The first impor- 
tant thing is a good history of the case. Pleural vomicae begin acutely 
with symptoms of pleurisy with effusion. After a variable time the 
acute symptoms abate, and the patient recovers to a certain degree, 
but he keeps on expectorating large quantities, "mouthfuls," of puru- 
lent matter. In others, there is a history of pneumonia, followed by 
empyema which broke through a bronchus. In still others, there is a 
history of an acute septic process, especially after a surgical operation, 
or after childbirth. Cases have been observed in which the pus in the 
pleural pocket came from an appendicular or hepatic abscess, the pus 
burrowing its way into the pleura, and then through the lung into a 
bronchus to the exterior. 

All cases give a history of an acute disease with fever, perhaps of the 
septic type, prostration, pain in the chest, and either primary or 
secondary pneumonia or pleurisy was diagnosticated at the time. 
The fever lasted a variable time, in some cases several weeks, when it 
suddenly dropped with the appearance of profuse expectoration of 
purulent material. The expectoration may come on suddenly with a 
gush, almost asphyxiating the patient. During the first few days the 
amount brought out is considerable. In a case under my care it was 
more than a pint. Within a few days the amount of sputum decreases, 
but it still remains relatively profuse for an indefinite time. It is 
during this chronic stage that tuberculosis is often diagnosticated. 
These patients cough, expectorate purulent sputum, often have 
hemoptysis, are emaciated, and run a subfebrile temperature, influ- 
enced by the amount of expectoration. When the latter is profuse, 
the fever is negligible, but during days when the communicating bron- 
chus is plugged, the fever is high. The cough and expectoration are 
influenced by posture; some cough more when lying on the affected 
side, while with others the reverse is true, apparently depending on the 
direction of the communicating fistula or bronchus. 

Physical exploration of the chest shows signs of an extensive basal 
31 



482 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

lesion, usually simulating the signs of a pleural effusion. In fact, the 
first one thinks of after going over such a chest is fluid, probably pus. 
But exploratory puncture fails to confirm it. In the cases in which 
the vomica is located in the region of the interlobar fissure, the signs 
are those of consolidation, or excavation of the upper part of the 
lung, though careful examination shows that the real apex of the lung 
remains unaffected, a fact which is of great diagnostic significance. 
The affected area is dull, more commonly flat, on percussion, and 
either feeble, cavernous, or amphoric breath sounds are heard, depend- 
ing on whether the cavity is filled with secretions or empty at the 
time of the examination. Large, moist rales, of a consonating character, 
are audible over the affected area. 

The differential diagnosis between this condition and phthisis is 
thus clear : The history points to an acute onset, as pleurisy or pneu- 
monia, or following some other septi^ process; the lesion is localized in 
the lower lobe, or in the region of the interlobar septum, while the apex 
of the lung remains free. These, combined with the fact that, despite 
its abundance, the sputum is negative, rules out tuberculosis. We have 
repeatedly emphasized that when the apex shows no signs of a lesion 
only positive sputum should justify the diagnosis of phthisis. 

Abscess of the Lung. — At times cases of pulmonary abscess, espe- 
cially the chronic form, are treated as advanced consumptives. A con- 
sideration of the history of the case should clear up the diagnosis in 
most cases. It is preceded by an attack of aspiration pneumonia, 
mainly after an operation, or after a septic pulmonary embolism. 
There are hectic fever, sweating, emaciation, and spasmodic cough, 
expelling large quantities of sputum which differs, as a rule, from that 
observed in phthisis. It has a brown color, due to an abundance of 
hematoidin crystals and elastic tissue fibers which may be found micro- 
scopically. Hemoptysis, at times copious hemorrhages, occur, and it 
is often this symptom that suggests phthisis to the patient and the 
physician. But here again the location of the lesion should clear up 
the diagnosis. It is usually in the lower lobe, while the apex remains 
free from pronounced pathological changes. I have seen several cases 
in which the lesion was in the upper lobe, especially in diabetics, or in 
persons on whom operations on the lower jaw were performed. Some 
of my cases began soon after operations on the tonsils. But in all, the 
history, the fact that the apex is free, the character of the sputum, and 
the absence of tubercle bacilli, are diagnostic points. 

Gangrene of the Lung. — When occurring as a sequel to aspiration 
pneumonia, pulmonary embolism, or after operations on the jaw in 
diabetics, or to the entry into the bronchi of foreign bodies such as 
teeth, fishbones, etc., gangrene of the lung is easily distinguished from 
phthisis by the history alone. But when occurring as a complication of 
bronchiectasis it is, at times, mistaken for tuberculosis: The history 
of cough and expectoration for many years is apt to prove misleading. 
When severe pulmonary hemorrhage is one of the symptoms, the diag- 
nosis of tuberculosis is fortified. 



PLATE XXI 



Fig. 1 



Fig. 2 





Pleural vomica. Dense homogeneous 
shadow in lower third of left side of the 
chest. Several dilated bronchi in left 
hilus region. Obliteration of left costo- 
phrenic sinus and displacement of the 
heart to the left. Note the absence of 
changes in the apices. 



Multiple bronchiectasis. Diffuse shadow 
in right hilus, middle lobe and portions 
of axillary regions, studded with bronchiec- 
tatic cavities. Obliteration of costophrenic 
sinus; pleuropericardial adhesions. Marked 
peribronchial changes in left lung. Supra- 
clavicular fields practically free from 
changes. 



Fig. 3 



Fig. 4 





Bronchiectasis. Large cavity with 
thick walls in upper lobe of right lung; 
thick pleura with dilated bronchi in 1 lower 
lobe; elevation of diaphragm. Left lung 
emphysematous; calcified nodule in second 
interspace. Dextrocardia. 



Metastatic hypernephroma of the lung. 
Autopsy. Sent in as tuberculous. Opaci- 
ties denoting infiltration of both apices. 
Effusion (hemorrhagic) into right pleura. 



PLATE XXII 

Fig. 1 Fig. 2 





Fig. 3 



Fig. 4 





Malignant tumor of the left lung. In the first radiogram the shadow could not 
be differentiated from a tuberculous lesion. It was only in the third radiogram, taken 
three months later, that the true nature of the affection could be made out radio- 
graphically. 



CANCER OF THE LUNG 483 

But fetid sputum is exceedingly rare in phthisis; as rare as gangrene 
is a complication of phthisis (see p. 499) . Gangrene is characterized by 
high irregular fever, prostration, cough, and expectoration of consider- 
able quantities of fluid, frothy, and highly offensive sputum which 
separates into three layers, the lowermost containing fragments of 
lung tissue. Elastic tissue is only rarely found in the sputum because 
it is soon destroyed by the rapid action of the pathogenic agent, but 
at times fragments of lung tissue may be discovered. None of these 
clinical features are seen in pulmonary tuberculosis, excepting when 
gangrene appears as a complication. 

Cancer of the Lung. — Intrathoracic neoplasms, especially carcinoma 
and sarcoma of the bronchi, lung and pleura, are often mistaken for 
tuberculous disease of the lung. The onset is insidious with cough and 
mild fever, the curve in some cases under my care having exquisitely 
simulated that seen in typical cases of incipient tuberculosis. When 
to this are added hemoptysis of various degrees, and loss in weight, it 
is clear that there are strong reasons for thinking of tuberculosis, the 
more common disease. Moreover, malignant disease of the lung is apt 
to pursue a very slow course. 

The differentiation is made by the symptomatology, the physical signs 
as well as with the aid of the a;-rays, though I consider the away find- 
ings less reliable in early cases than careful physical exploration of the 
chest (see Plates XXI and XXII). While growing, the tumor gives 
rise to certain pressure symptoms which are of immense value in the 
differential diagnosis. Pressing upon the superior vena cava, enlarged 
veins on the chest wall and shoulder or anterior part of the neck are 
produced; pressure on the sympathetic will dilate the pupil on the 
affected side. There may be a difference in the fulness of the pulse 
when the two radials are compared. These signs are invaluable, but 
they are as often absent as present. 

At the beginning of the disease, when the new growth is yet insig- 
nificantly small, the physical signs may not show any alterations in the 
resonance and breath-sounds, and the constitutional symptoms of 
tuberculosis may be so striking as to mislead. But it appears that in 
nearly all cases, even those showing a subfebrile temperature, the pulse 
is normal, which is rare in tuberculosis. In some cases I have noted 
symptoms and signs of pulmonary emphysema, with slight fever and 
hemoptysis. Here again the diagnosis was difficult and required 
prolonged observation before a conclusion could be arrived at. 

With the growth of the tumor, local signs may be made out by 
physical examination. If the neoplasm is located in the upper part of 
the chest, the signs again simulate tuberculosis, but a careful analysis 
of the findings usually shows striking differences. Emaciation appears 
early in phthisis, while in cancer of the lung the nutrition of the patient 
may leave little to be desired for many months. Even in the later 
stages, when the patient loses in weight considerably and progressively, 
the cachexia differs markedly from that of tuberculosis. In the latter 



484 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

the patient appears hectic, while in the former the waxy yellow tinge 
of cancerous cachexia is almost invariably noted at first sight; the 
severe blanching of the face also betrays malignant disease. But, as 
was already stated, cachexia appears late in intrathoracic tumor, 
while in tuberculosis it is often an early symptom. 

Percussion over the site of the tumor elicits a flat note, which is 
never found in tuberculosis of the upper lobe. Moreover, above the 
area of flatness there is an area of resonance, again unknown in tuber- 
culous lesions. The affected side of the chest in many cases may thus 
be found to be made up of three zones: an upper, resonant one, above 
the second rib; a middle one, from the second rib for one or two inter- 
spaces, which is flat, and the lowermost again resonant. The upper 
area of resonance should immediately excite suspicion. When the 
growth appears first in the lower parts of the chest tuberculosis should 
not at all be thought of, but often pleural effusion is simulated, but 
this is excluded very easily, in most cases by the history, course, and 
physical signs. 

Auscultation also gives very valuable clues. If the tumor is of some 
dimensions, there will be noted feeble or complete absence of breath 
sounds over the circumscribed area which has been found flat on per- 
cussion. Now, in tuberculous lesions with such extensive implication 
there are almost invariably to be heard adventitious sounds, usually 
large, moist, and consonating rales. It may thus be stated that a very 
dull or flat note, with feeble breath sounds, without any rales is strongly 
suggestive of a tumor. The reasons for the absence of breath sounds are 
these : The tumor often arises from the wall of a large bronchus and 
with its growth it compresses the air tube; or when one of the medias- 
tinal glands is the source of the tumor, its growth may compress a 
large bronchus in its vicinity. These signs, combined with the lack of 
the toxic symptoms of phthisis, especially the lack of tachycardia, 
are sufficient to direct attention to the problem of malignancy, even in 
the presence of such symptoms as cough, slight fever, hemoptysis, etc. 

With the growth of the tumor the area of flatness increases, the 
veins on the chest become more and more prominent, and at times 
metastatic deposits are discovered in the glands above the clavicles, 
etc. A good sign to be considered is the position of the trachea and 
the heart : In tuberculosis with such extensive involvement these two 
organs are drawn toward the affected side, while in cancer of the lung 
they are pushed away toward the unaffected side. This sign has 
served me often in doubtful cases. 

Malignant tumors of the pleura or lung are apt to be complicated 
by pleural effusions, in many cases serous, in others serosanguineous, 
while at times it is purulent. If the diagnosis has not been previously 
made, the difficulties increase when this occurs. The fluid is often 
sanguineous, but this does not help us, because it is often so in phthisis. 
The pressure signs enumerated above are, however, more likely to 
occur in cancer. A careful watch for metastases may clear up an 



ACTINOMYCOSIS 485 

otherwise obscure case. We must, however, again emphasize that 
when blood is found at the first exploratory puncture, it is of greater 
diagnostic significance than when found at the second puncture, 
because tapping the chest, at times, causes bleeding, thus coloring the 
effusion. Purulent effusions of cancer are not uncommon. At times 
fragments of the growth or characteristic cells are found in the centri- 
fuged specimen of the aspirated fluid, but this is rare in my experience. 
It has been stated that when a large number of coarsely granular 
eosinophile cells are found in the fluid it is a good sign of tumor of the 
pleura or lung. 

I have observed several in cases in which the first symptoms and 
signs were those of pulmonary emphysema, only the persistent unpro- 
ductive cough, slight fever, and hemoptysis drawing the attention of 
the patient to the seriousness of the disease. The dyspnea may be 
severe, and in one case it was even distinctly stridorous, due to pressure 
of the growth cr the implicated tracheal glands on the trachea. In a 
few cases I have seen distinct pulsations of the thorax, especially when 
the tumor appeared in the upper part of the chest. These pulsations 
could be perceived by palpation. These signs are not all present in 
every patient, still some may be found in each case, and should be 
considered before a diagnosis is made. 

Actinomycosis. — Actinomycosis of the lung, in its initial stages, 
presents symptoms and signs not unlike those of pulmonary tubercu- 
losis. There are cough, loss of flesh, mild fever, etc. So long as the 
fungus remains within the lung there may be little or no expectoration 
and the sputum is microscopically negative. When it makes its way 
into a bronchus, a microscopic examination may reveal the fungus, 
if it is looked for. When it reaches the pleura, symptoms of pleurisy 
with effusion arise and the patient is for a time treated for tuberculous 
pleurisy or empyema. The constitutional symptoms in advanced 
cases of actinomycosis simulate those of active and advanced phthisis 
very strikingly. There are hectic fever, tachycardia, emaciation, cough 
and expectoration of large quantities of nummular sputum, hemop- 
tysis, etc. 

In the initial and latent stages actinomycosis differs from phthisis 
in the following points : Tuberculous lesions begin at the apex almost 
invariably, while actinomycosis is usually localized in the middle or 
lower lobe. We have already repeatedly warned against a diagnosis of 
tuberculosis when the apex remains unaffected. There are, however, 
cases of actinomycosis in which the upper lobe of the lung is the first 
to be affected. Because at this stage tubercle bacilli and elastic tissue 
may be absent in phthisical patients, the difficulties are at times 
insurmountable. A careful search should be made for the ray fungus 
in all doubtful cases. 

The diagnosis is usually cleared up within a few weeks when a fluc- 
tuating swelling appears on the chest wall, which may suggest empyema 
necessitatis, especially since there are also signs of a pleural effusion. 



486 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

But an examination of the sputum, or of the pus removed from the 
external swelling, shows yellowish granules or streaks of actino- 
mycotic growth. 

Streptotrichosis of the Lung. — Nocardia. — Infection with any of the 
microorganisms of the streptothrix group may give symptoms which are 
often mistaken for those of chronic pulmonary tuberculosis. Of late, 
many cases have been reported in this country, while in Europe these 
infections have been described as pseudotuberculosis. In 1898 Simon 
Flexner 1 described a case of this "pseudotuberculosis" with autopsy. 
More recently Edith J. Claypole, 2 William M. Stockwell, 3 and others, 
have reported cases in this country. 

The symptoms are those of chronic phthisis. The onset is slow and 
insidious. The patient coughs, expectorates mucopurulent material, 
and is short-winded. Hemoptysis is not uncommon though profuse 
pulmonary hemorrhages are not observed. Either streaky sputum or 
small amounts of blood are brought out. The symptoms of toxemia, 
such as fever, nightsweats, tachycardia, etc., are usually wanting. 
Most patients present a rather good external appearance despite the 
symptoms of pulmonary trouble which may have lasted for years. It 
seems that most patients are treated as tuberculous with negative 
sputum, and are admitted to sanatoriums and hospitals for advanced 
consumptives. 

The differential diagnosis can only be made by a microscopic 
examination of the sputum, of which large quantities should be obtained 
for the purpose. Inasmuch as the staining methods employed to 
discover tubercle bacilli render the streptothrix invisible, and some of 
the strains are acid-alcohol-fast, great care should be taken in gauging 
the amount of the decolorization of the carbol-fuchsin preparations, 
which should be varied so as to differentiate the less acid-fast types. 
The Gram-method of staining may also be employed. There are strong 
reasons for believing that if special care were taken with all sputum- 
negative cases showing signs of chronic tuberculosis, more cases of 
pulmonary streptotrichosis would be discovered. Claypole 4 believed 
that she had worked out a certain serological reaction w T hich she recom- 
mended as of diagnostic value in streptothrix, but considering the large 
number of types of this microorganism, it is problematical whether a 
single skin reaction will be efficient diagnostically. 

Bronchopulmonary Spirochetosis. — Hemorrhagic Bronchitis. — This 
disease was first observed in Ceylon and described by A. Castellani in 
1905. Later Jackson reported cases in the Philippine Islands, and dur- 
ing the recent World War, many cases were discovered among the 
troops in France, Belgium, Italy, England, Switzerland, etc. In a 
soldiers' sanatorium in Northern Italy, Castellani 5 found that 3 per 

1 Jour. Exper. Med., 1898, iii, 435. 

2 Arch. Int. Med., 1914, xiv, 104. 

8 Tr. Nat. Assn. for Study and Prev. Tuberc, 1916, xii, 265. 
* Jour. Exper. Med., 1913, xvii, 99. 
sPresse Med., 1917, xxv, 377. 



PULMONARY LESIONS IN CARDIAC PATIENTS 487 

cent, of the patients sent in with the diagnosis of pulmonary tuber- 
culosis, in reality suffered from bronchopulmonary spirochetosis. 
Similar experiences have been recorded in France. 

The symptoms are akin to those of pulmonary tuberculosis, and most 
patients are treated as such. As given by H. Violle, 1 there is cough, 
more or less copious expectoration, but fever is lacking in the majority 
of cases, while the general condition of the patient leaves little to be 
desired. Violle states that the gross appearance of the sputum is 
characteristic and that a diagnosis can be made by examining it alone. 
The expectoration is viscid, uniformly thick and closely resembles the 
juice of gooseberries. But what makes the symptomatology like that of 
phthisis is the pulmonary hemorrhage which is never lacking. The blood 
brought out may be considerable and is of a peculiar pinkish color; 
fatal hemorrhage, however, never occurs. P. Nolf and P. Spehl 2 
describe cases without hemoptysis. In these cases the sputum was 
mucopurulent, yellowish-green in color, and after some days became 
fetid, the fetor remaining pari passu with the number of spirilla. 

Physical exploration of the chest may reveal nothing, or some signs 
of bronchitis may be discovered. In rare cases signs of consolidation 
of an apex or any part of the lung have been found. S. Fishera 3 
reports cases of apical catarrh running a chronic course with fever, 
loss of flesh, nightsweats, and blood-stained sputum containing spiro- 
chete, but no tubercle bacilli. 

The differentiation from phthisis can be made only by a microscopic 
examination of the sputum. The spirochete bronchialis are found in 
large numbers; in some cases the specimens are actually teeming with 
them. They may be stained with the Romano wski stain, but the 
silver nitrate stain of Fontana-Tribeudeau is superior. The organism 
is extremely variable in shape, length, and number of spirals. It has not 
yet been cultivated, but Chalmers and O'Farrell have succeeded in 
inoculating monkeys by intratracheal injections of a patient's sputum. 
The prognosis is generally favorable in acute cases, but when the disease 
runs a chronic course it may last indefinitely, with occasional remissions. 

The differentiation from phthisis is thus made by the following 
criteria: Absence of tubercle bacilli, of hyphomycetes, and of ova of 
Paragonimus westermanii from the sputum, while the Spirochete 
bronchialis are found. 

Pulmonary Lesions in Cardiac Patients. — Patients suffering from 
organic heart disease, especially mitral stenosis, often cough, expecto- 
rate, spit blood, have mild fever, and are emaciated, and for these 
reasons are very frequently treated for tuberculosis. Several cases of 
mitral stenosis are annually sent into my wards in the Montefiore 
Hospital as tuberculous, and in my private practice I have very fre- 
quently cases presented tome as tuberculous, though they only suffer 

1 Bull. Acad, de Med., Paris, 1918, lxxix, 429; Lancet, 1918, ii, 775. 

2 Arch. Med. Beiges, 1918, lxxi, 1. 

3 Riforma Medica, 1918, xxxiv, 384. 



488 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

from mitral obstruction. The main reason is the frequency of hemop- 
tysis in mitral stenosis, which, as has already been mentioned, next 
in frequency to tuberculosis is a cause of blood spitting. The amount 
of blood expectorated may be slight, only streaky, and in rare cases 
even copious. I have observed it in fully compensated cardiac lesions, 
and in those with signs of decompensation. In the former, the hyper- 
trophied heart pumps the blood through the pulmonary vessels with 
great vigor, and because of the obstruction it meets while passing 
through the narrowed mitral valve, the pressure is increased, rupturing 
some of the capillaries. It is for this reason that we meet at times with 
hemoptysis in patients in whom compensation is as perfect as could 
be expected. In cases of heart failure also hemoptysis occurs, at times, 
due to hemorrhagic infarction or embolism; though embolism may be 
said to be an infrequent cause, and when it does occur, it is due to an 
antemortem clot in the right auricular appendix. The symptoms are 
clear-cut, but I have seen many in which tuberculosis was diagnosti- 
cated. It usually occurs suddenly, producing acute pain in the chest, 
dyspnea, orthopnea, cyanosis, and hemorrhage, at times very copious. 
In other cases the bleeding is due to thrombosis of the pulmonary 
vessels, and then the accompanying symptoms are less acute. 

In chronic cases of mitral stenosis in which cough, emaciation, hemop- 
tysis, etc., suggest a tuberculous process the following points of differ- 
entiation are to be borne in mind : Dyspnea on exertion is more pro- 
nounced, in cardiac than in pulmonary patients. We have already 
shown that dyspnea is not one of the cardinal symptoms of phthisis in its 
early stage (see p. 240). Rest for a few days will relieve the dyspnea 
of cardiacs. The cough in cardiacs is aggravated during the cold 
weather, or when the patient walks against the wind, and not influ- 
enced much by sedative medication (heroin, codein, etc.) which relieve 
the cough in the tuberculous. Digitalis, however, often relieves the 
cough of cardiacs. In the tuberculous the heart is smaller, at least not 
larger, than normal, while hypertrophy or dilatation may be made out 
in nearly all cases of mitral stenosis. 

Physical exploration of the chest may show some areas of atelec- 
tasis, catarrh, or localized pulmonary edema, simulating phthisical 
lesions. Owing to brown induration, the signs elicited over the apical 
area are those of consolidation, in some cases. In most cases, however, 
the resonance above the clavicle is not impaired. Rales, when heard, 
are found over the lower parts of the chest and bilaterally, and they 
are not constant, because they are due to localized edema of the lung. 
The cardiac murmur characteristic of mitral stenosis usually decides 
the diagnosis. In the rare cases of mitral stenosis without murmurs, 
or when the murmur disappears owing to decompensation, we usually 
find an accentuation or reduplication of the second sound in the second 
intercostal space near the left border of the sternum. At the apex 
the first sound often has a slapping character. Percussion shows 



PLATE XXIII 



Fig. 1 



Fig. 2 





Syphilis of the lung simulating in the 
radiogram a tuberculous lesion in the 
right apex. 



Pulmonary syphilis. Diffuse peribron- 
chial infiltrations of right lung, mostly 
marked at the lower half. Hilus glands in 
left lung are distinctly enlarged. Peri- 
cardial adhesions mainly seen in right 
side. 



Fig. 3 



Fig. 4 





Moderate calcification at the hilus on 
both sides. Right diaphragm elevated. 
Heart enlarged, aorta dilated. Both 
apices free. Clinical diagnosis, syphilis of 
the lung. Admitted as tuberculous, and 
treated as such for many years. 



Malignant growth; empyema. Homo- 
geneous shadow obscuring left lung field. 
Because the heart is pulled toward the left, 
the radiogram cannot decide whether it is 
due to a thick pleura and parenchymatous 
lesion, or to an effusion. Right lung 
emphysematous and also shows a slight 
infiltration of the apex. 



SYPHILIS OF THE LUXG 489 

enlargement of the area of cardiac dulness and in cases of decompensa- 
tion some form of arrhythmia, usually that of auricular fibrillation, 
may be noted, all of which are lacking in phthisis. 

These signs should be sought for in every case of cough and hemop- 
tysis in which the signs of pulmonary tuberculosis are not clearly 
noted. While it is possible that patients with mitral stenosis should 
become tuberculous, yet this is exceedingly rare. In fact, it has been 
my rule never to diagnosticate tuberculosis in one showing signs of dis- 
ease of the mitral valve and cardiac hypertrophy or dilatation, irrespective 
of the physical signs elicited ivhile examining the lungs, unless the sputum 
reveals tubercle bacilli. I have hardly seen more than a half dozen 
cases of mitral stenosis developing phthisis. 

Pulmonary infarction occurring during the course of cardiac dis- 
ease, or from an embolus arriving from some distant diseased vein, 
may be a source of error, as I have seen in several cases. The patient 
knows that he has an organic heart lesion, or phlebitis, and perhaps 
has been treated for these conditions. Suddenly, without any warn- 
ing, he is seized with severe pain in the chest, distressing dyspnea, or 
orthopnea, and hemoptysis. In some the bleeding is very copious, 
even threatening life. After the acute symptoms have been amelio- 
rated, an examination shows signs of a localized area of diseased lung : 
Impaired resonance, feeble, or bronchial, breath sounds, and moist 
rales. These physical signs are mostly found in one of the lower lobes, 
but may also occur in the middle or upper lobes, especially in the inter- 
scapular space. But the history, as well as the signs of a cardiac lesion, 
or of phlebitis, should clear up the diagnosis in most cases. However, I 
have seen many patients with mitral stenosis, or with remnants of 
pulmonary infarction, treated for an indefinite period in tuberculosis 
clinics in New York City, and others who have been admitted to 
sanatorium s and kept there for months. 

In acute endocarditis and pericarditis, rheumatic or infectious, 
symptoms of tuberculosis may be present. There are fever, tachy- 
cardia, emaciation, hemoptysis, and some of the physical signs of acute 
miliary tuberculosis. In most cases no murmur is audible, and the 
area of cardiac dulness may not be found increased perceptibly. 
When to all this there is added a pleural effusion, which is not uncom- 
mon, the diagnosis of tuberculosis appears inevitable. But a careful 
inquiry into the history of the onset of the disease, as well as the fact 
that the pleural effusion is bilateral, should excite suspicion. Patients 
with acute articular rheumatism when showing some signs or symp- 
toms of tuberculosis should not be considered tuberculous without 
positive proof, or a careful study of the course of the disease. Signs 
of pericardial effusion are also indications that we are dealing with a 
cardiac, and not with a tuberculous lesion. 

Syphilis of the Lung.— Syphilis of the lung is an extremely rare 
disease, and when it does occur it is very difficult of diagnosis patho- 



490 DIAGNOSIS OF PULMONARY TUBERCULOSIS 

logically as well as clinically. According to- Osier, 1 of 2500 autopsies 
at Johns Hopkins Hospital, lesions which were believed to be syphilitic 
were present only in 12 cases. In a study which included all the London 
Museums, J. K. Fowler 2 was only able to discover twelve specimens, 
and two of these were of a doubtful nature. Among 6000 cases of 
syphilis at the hospital at Copenhagen , syphilis of the lung was observed 
only in 2; and among 18 patients with acquired syphilis who came 
to autopsy, gummatous lesions of the lung were found three times. 
Chiari 3 found only 2 cases of syphilitic lesions of the trachea and 
bronchi, and 1 of syphilis of the lung. Petersen among 88 autopsies of 
patients with acquired syphilis found lung lesions only in eleven. 
The rarity of pulmonary syphilis, despite the fact that syphilis is so 
widespread, testifies that errors in diagnosis are at least as rare as the 
disease. But now and then we meet with a case which shows symptoms 
simulating pulmonary tuberculosis and treated as such. 

Syphilis of the lung manifests itself by the usual symptoms of 
chronic pulmonary tuberculosis, such as cough, expectoration, slight 
fever, loss in weight, and at times even hemoptysis. But it appears 
that in nearly all cases the course of the disease is rather slow; in none 
of the cases observed by the wTiter has the disease pursued a progres- 
sive course, nor has it perceptibly disabled the patient. Physical 
exploration of the chest shows that the lesion is localized in the lower 
or middle lobe, and the apex remains practically free from changes. 
This alone should excite suspicion that it is not tuberculous. A careful 
search should be made for the stigmata of syphilis in the bones, skin, 
larynx, rhinopharynx, eyes, etc. The Wassermann reaction may be 
of help, but not so much as would be anticipated, because it is fre- 
quently positive in tuberculosis, and phthisical subjects may have had 
syphilis. In fact, the two diseases are found concurrently very fre- 
quently. Absence of tubercle bacilli from the sputum is no criterion, 
because in really syphilitic phthisis the amount expectorated is rather 
scanty, at least in the early stages. 

The best differentiation is made by the application of the thera- 
peutic test. Properly administered doses of salvarsan, mercury, or 
iodide of potassium will promptly remove the symptoms of syphilitic 
phthisis. In some of my cases the effect was very prompt, within a 
couple of weeks the cough disappeared, weight and strength returned, 
and the patient considered himself well. But this does not imply 
that in the least suspicious case a diagnosis of syphilis of the lung 
should be made and treatment applied. Patients with pulmonary 
tuberculosis are often harmed by antisyphilitic treatment, especially 
mercury and the iodides. Considering the extreme rarity of syphilis 
of the lung, it is clear that Fowler's suggestions should always be 

1 D'Arcy Power's System of Syphilis, London, 1914, iii, 15. 

2 Diseases of the Lungs, London, 1898. 

3 Quoted from F. Balzer, Brouardel-Gilbert-Thoinot, Traite de Medecine, Paris, 1910, 
xxix, 641. 



HYPERTHYROIDISM 491 

borne in mind: (1) The cases must be complete, that is, the symptoms 
observed during life must be considered in connection with the lesions 
discovered on postmortem examination. (2) The evidence of syphilitic 
infection must be undoubted. (3) Repeated examinations of the 
sputum must have been made, and tubercle bacilli have been invari- 
ably absent, and the absence of tubercle from the lungs as the cause 
of the lesions must be proved by postmortem examination. (4) 
Syphilitic lesions about the nature of which there can be no doubt 
must be found in other organs. 

Many tuberculous patients also suffer from syphilis, as has already 
been mentioned. When tubercle bacilli are implanted on a syphilitic 
subject it modifies the course of phthisis rather favorably, probably 
because it is characterized by a tendency to the production of con- 
nective tissue (see p. 524). It must always be borne in mind that the 
presence of syphilis does not exclude phthisis, but that the latter is 
very often engrafted on the former. 

Hyperthyroidism. — The syndrome of hyperthyroidism, which is so 
commonly met with in young persons, is very frequently mistaken 
for phthisis. The acceleration of the pulse-rate, the frequent sweating 
at the least provocation, the slightly elevated temperature, and the 
tendency to fatigue and languor, are suggestive of the symptoms of 
early phthisis, especially when the patient coughs for any reason. 
On the other hand, symptoms and signs of disturbance of the auto- 
nomic nervous system are very frequently seen in phthisis, as has 
recently been shown from Meyer Solis-Cohen's 1 studies. Many cases 
of the milder grades of hyperthyroidism are therefore treated for 
tuberculosis. 

The severe cases of this syndrome, those showing the cardinal signs 
of Grave's disease, goiter, tachycardia, tremor, and exophthalmus are 
not likely to be mistaken for phthisis, unless that latter appears as a 
complication of the former. But mistakes may be avoided even in 
the milder forms of hyperthyroidism when the following points are 
considered: Patients with tachycardia, liability to sweat at the least 
exertion or excitement, languor, dermographism, etc., are not to be 
considered tuberculous unless a physical examination of the chest, and 
perhaps radiography, reveals a distinct pulmonary lesion. In doubtful 
cases it may be advisable to wait for the results of repeated sputum 
examinations. Otherwise the characteristic symptom of hyper- 
thyroidism, rapid heart action, palpitation, fatigue, flushes, sweats 
more during the day than during the night, a slight tremor of the 
fingers, etc., are sufficient to define the nature of the trouble. In 
some cases, showing signs of collapse induration (see p. 474), only 
prolonged observation will clear up the diagnosis. 

i Am. Rev. Tuberculosis, 1917, i, 289. 



CHAPTER XXIX. 



COMPLICATIONS OF PHTHISIS. 




Most of the pathological processes described as complications of 
phthisis are part and parcel of the tuberculous disease in the lungs or 
symptoms of the disease which, at times, assume the ascendency. 
This is the case with hemoptysis, ulceration and amyloid degeneration 
of the intestines, tuberculosis of the larynx, kidneys, meninges, etc. 
Many of these conditions have been discussed while speaking of the 
symptomatology of phthisis. Pleural complications, such as pleurisy, 
pneumothorax, etc., are treated in special chapters. Here a few of the 
more important complicating processes, which may have an influence 
on the course or the prognosis of pulmonary tuberculosis, will be 
discussed. 

Influenza. — Influenza is more often diagnosed in tuberculous patients 
than it actually occurs. Any acute exacerbation of the tuberculous 
process is apt to be attributed by the patient to a "cold," and by 
physicians to influenza. It is for this reason that influenza is dreaded 
by medical men treating tuberculous patients, and aggravations of the 
tuberculous disease are credited to influenza in cases in which this 
complication had never occurred. 

During the epidemic of influenza of 1918 we have had an oppor- 
tunity to study the effects of influenza on tuberculous patients exten- 
sively. At the Montefiore Hospital the patients in one part of the 
tuberculosis pavilion were attacked, while those in the other three 
parts were almost entirely spared. The symptomatology of the dis- 
ease was about the same as that observed in non-tuberculous patients, 
excepting that complicating bronchopneumonia had been observed 
in but few cases. Similar experiences are reported by Dr. B. Stivelman, 
Superintendent of the Bedford Sanatorium. Of a total of 238 patients 
and staff, 60 were affected during the epidemic of influenza. In only 
10 pneumonia occurred, and of these 4 died. They were all advanced 
cases of phthisis; one had an artificial pneumothorax, etc. It appears 
that here the patients who recovered, just as those at the Montefiore 
Hospital, have not shown any tendency to progression of the disease. 
The lesions remained in about the same condition as before the com- 
plicating influenza occurred. 

Among patients in private practice I have seen many who were 
attacked by influenza, and in hardly any has the tuberculous process 
in the lung been aggravated; convalescence was rapid and most of 
them soon regained their weight and strength. In those who suffered 



LARYNGEAL TUBERCULOSIS 



493 



from pneumonia the outlook was about 
the same as in non-tuberculous indi- 
viduals. Moreover, I have not seen 
a single case of tuberculosis which has 
appa rently been engendered by influenza, 
though many patients have consulted 
me along these lines. 

All this tends to show that the ten- 
dency to attribute acute febrile attacks 
seen in tuberculous patients to " influ- 
enza" is unjustified. They are usually 
acute exacerbations of the tuberculous 
process and, excepting during epi- 
demics, have nothing to do with in- 
fluenza. 

As will be seen from the temperature 
chart (Fig. 80), patients with normal 
or but slightly elevated temperature 
suffered from pyrexia during the 
course of the influenza for seven to 
twelve days, and then the fever de- 
clined. They remained weak and 
debilitated, but the lesion in the lungs 
remained about the same as it was be- 
fore the occurrence of the influenza. 
On the other hand, in patients running 
high fever due to the tuberculous lung 
lesion, the complicating disease was 
the last spark. They succumbed to 
hyperpyrexia, and complicating bron- 
chopneumonia (see Fig. 81). 

Influenza attacking tuberculous 
persons may have no effect on the 
primary disease so long as the patient 
is properly cared for immediately at 
the onset of the complication, and the 
lung lesion is not of an acute and pro- 
gressive type. When permitted to 
walk around while having influenza, 
complicating bronchopneumonia may 
ensue, or the tuberculous lung lesion 
may be stirred into greater activity, 
and the outlook is very grave. 

Laryngeal Tuberculosis. — The 
frequency of this complication 
during the course of phthisis has 
been differently stated by various 





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COMPLICATIONS OF PHTHISIS 



authors. The proportion varies from 5 to 50 per cent. Harold Bar- 
well found at the Mount Vernon Sanatorium 11.69 per cent, among 
1541 tuberculous patients; Brandenburg, 9.16 per cent.; John B. 
Hawes, 1 only 8 per cent, among 1245 patients. Even sanatoriums, 
which do not admit patients w v ith laryngeal complications, have 
many with this disorder. Thus at Otisville, N. Y., Julius Dworetzky 2 
found that 25.6 per cent, had laryngeal tuberculosis. Among 100 
tuberculous children under fourteen years of age Dwozetzky found no 
case of laryngeal tuberculosis. It seems that the proportion found 
depends on the zeal displayed by the laryngologists looking for it. 
Percy Kidd 3 found that 50 per cent, of fatal cases of phthisis showed 
tuberculous laryngitis at the autopsy, and of these only 20 to 50 per 
cent. w T ere recognized during life. The estimate that one out of three 
patients with active phthisis has a laryngeal lesion appears to be 
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Fig. 81. — Influenza in a patient with progressive tuberculosis. Fatal in one week. 

Laryngeal tuberculosis spells phthisis; primary tuberculosis of this 
organ is so exceedingly rare as to constitute a medical curiosity. It is 
more frequent among males than among females, the proportion being, 
according to Morel Mackenzie, 2.7 of the former to 1 of the latter. 
The reason for this disparity is that men are altogether more liable to 
throat affections, probably because of the abuse of tobacco, alcohol, 
and exposure to irritation by dust at their occupations. It is also 
likely to be more severe in men than in women. 

Symptoms. — These depend on the location of the lesion in the larynx. 
Those in whom the interior of the larynx is affected do not suffer as 
much as those whose trouble lies at the entrance of the larynx. The 
symptoms are few in number. Hoarseness is present in all in whom 
the interior of the larynx is affected, and it may be of various degrees, 
from mild tiring of the voice to complete aphonia. On the other hand, 
pain is more frequent when the entrance of the larynx, especially the 
epiglottis, is affected, while the voice may in these cases be retained 

1 Boston Med. and Surg. Jour., 1914, clxxi, 19. 

2 Ann. Otol., Rhinol., and Laryngol., 1914, xxiii, 835. 

3 Allbutt's System of Medicine, v, 210. 



LARYNGEAL TUBERCULOSIS 495 

quite well. The pain may be spontaneous, radiating to the ear, or there 
may be a sensation of tickling which provokes cough. In advanced 
cases, with perichondritis, deep ulceration of the epiglottis, and col- 
lateral inflammatory edema of the parts, the pain may be so severe 
as to interfere with swallowing food. Usually warm fluids and solids 
cannot be passed. The dysphagia may be so severe as to prevent 
swallowing altogether. I have seen some cases in which swallowing 
of saliva was more painful than that of food. Local external tenderness 
is rare. Stridor, and obstruction of respiration, are comparatively rare, 
but they do occur now and then. Julius Dworetzky, whose experience 
has been immense, classifies the clinical course of laryngeal tuberculosis 
into the acute, subacute, and the chronic types. The least frequent is 
the acute type, which is characterized by a soft edema of the larynx 
with a marked tendency to ulceration and no tendency to fibrosis. It 




Fig. 82. — Tuberculosis of the larynx. (Ballenger.) 

is usually found in far advanced cases, but may, on rare occasions, be 
met with in incipients. Hoarseness, a sensation of fulness in the throat, 
dysphagia, etc., are very much accentuated. The outlook is grave; 
nearly all patients succumb within a few months. The subacute type 
shows a moderate tendency to fibrosis of the lesion. Papilliform infil- 
trates and soft polypoid excrescences are usually found laryngo- 
scopically. When the true vocal cords or the interarytenoid sulcus are 
involved, hoarseness is a clinical feature of these cases. The prognosis 
is favorable, especially if proper treatment is instituted. In the chronic 
type the tendency to fibrosis and healing is strongly marked. The symp- 
toms referable to the larynx are mild, or may be lacking altogether. 
The prognosis is excellent. It is this type of laryngeal tuberculosis 
which may exist for a long time without annoying the patient very 
much. 



496 



COMPLICATIONS OF PHTHISIS 



Diagnosis. — Considering the immense prognostic significance of 
laryngeal tuberculosis, we must be guarded in making a diagnosis 
of this complication. Hoarseness alone is insufficient for a diagnosis 





Fig. 83. — Incipient tuberculosis of the 
larynx. Infiltration of posterior com- 
missure with slight thickening of aryte- 
noids. (Dworetzky.) 



Fig. 84. — Chronic tuberculosis of the 
larynx. Papillomatous infiltration of 
posterior half of right cord with slight 
thickening at interarytenoid space. 
(Dworetzky.) 



because it may be absent when the larynx is implicated but the vocal 
cords remain in good shape; or it may be present in a patient suffering 
from phthisis, yet no tuberculous lesion is discoverable in the larynx. 
This is seen when the right recurrent laryngeal nerve is implicated in 





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; -v.^V- , --,-••■.■ 




Fig. 85. — Chronic tuberculosis of 
the larynx. Left cord thickened owing 
to tuberculous infiltration; right cord 
slightly so. Slight interarytenoid 
thickening. (Dworetzky.) 



Fig. 86. — Marked infiltration of epiglot- 
tis; pear-shaped arytenoids. Infiltration and 
erosions of both false and true cords. 
(Dworetsky.) 



a thickened right apical pleural lesion, or when the two laryngeal 
nerves are pressed upon by enlarged tracheal glands. It must also be 
borne in^mind that simple chronic laryngitis and pharyngitis are 



LARYNGEAL TUBERCULOSIS 



497 



extremely common in phthisical subjects, as has been pointed out by 
Harold S. Barwell, 1 and they may cause hoarseness and throat discom- 
fort. The constant coughing and the irritation of the sputum passing 
through the larynx may produce a simple laryngeal catarrh. 

W. Freudenthal 2 urges that lasting hoarseness, apparently due to 
simple laryngitis, and seen in a patient who is not presenting symptoms 
of alcoholism or constitutional diseases, as gout or rheumatism, should 
excite suspicion of tuberculosis. 

The diagnosis of tuberculous laryngitis is quite easy when there are 
ulcerations but in the incipient stage it appears to be just as difficult 
as the diagnosis of incipient pulmonary tuberculosis. Laryngologists 
usually enumerate the laryngoscopic signs of advanced disease, evi- 
dently because they mostly see advanced cases. 




Fig. 87. — Far advanced tuberculosis of 
the larynx. Erosion of the entire right 
vocal cord; infiltration and erosion of 
right ventricular band. " Mouse-eaten " 
appearance of the left cord and hyper- 
plasia of posterior commissure ; infiltra- 
tion of both arytenoids. (Dworetsky.) 




Fig. 88. — Erosion of right half of 
epiglottis and right aryepiglottidean 
fold. Ulceration of right arytenoid. 
(Dworetsky.) 



Some authors have maintained that the tuberculous larynx is char- 
acterized by pallor of the mucous membrane. But it appears that pal- 
lor alone is insufficient for a diagnosis, because the larynx shares the 
pallor of the fauces which is seen in most tuberculous patients; it is 
also found in those who suffer from severe anemia of any kind. In 
fact, there are just as many red and congested larynges in phthisical 
subjects as pale ones. 

Paresis of the vocal cord on the side of the lung lesion, associated 
with slight chronic laryngitis, is one of the signs of incipient tubercu- 
losis of the larynx, according to many authors, notably F. Stern. 3 He 
calls this the " larynx sign" of early pulmonary tuberculosis and advises 
direct visual inspection to detect it when there is a sensation of vague 
oppression of the chest, a tendency to rheumatic pains, slightly 



lancet, 1909, i, 1249. 

3 Berl. klin. Wchnschr., 1914, 

32 



2 Ztschr. f. Tuberkulose, 
1419. 



1910, xvi, 338, 



498 COMPLICATIONS OF PHTHISIS 

irregular breathing, or gastric disturbances. The entrance to the throat 
is moderately red, and the paralyzed vocal cord is also red. There is 
always more mucus on the paretic cord than on the other, and its 
inner margin is usually irregular in outline. There is slight hoarse- 
ness, particularly at night and the patient hawks often, but raises 
very little sputum, and tubercle bacilli may not be found at this early 
stage. 

Thickening and even ulceration of the posterior wall of the larynx 
is another early sign. Uniform redness of both vocal cords is not 
pathognomonic of tuberculosis, but when one cord is red while the 
other remains normal or is pale, tuberculosis is probably present. 

With the advance of the process the smooth and shiny appearance 
of the parts is changed owing to the ulceration. The infiltration often 
affects the epiglottis, producing that pale, rounded, sausage-like body 
which may attain such dimensions as to obstruct the view of the inte- 
rior of the larynx. The arytenoid cartilages often change into pyriform 
bodies. When the infiltration begins to ulcerate, the characteristic 
worm-eaten appearance of the parts is seen, together with caries, 
perichondritis, necrosis, and exfoliation of parts of the cartilages. 

In cases in which the infiltration begins in one or both vocal cords 
or the ventricular bands, or the interarytenoid region, the prognosis 
is more favorable. However, one or both cords may be destroyed by 
ulceration. In far-advanced cases all parts may be destroyed, includ- 
ing the epiglottis, of which only a short stump may be left. 

Prognosis. — The outlook in phthisis complicated by tuberculous laryn- 
gitis is rather gloomy, though not invariably fatal, as teas once thought. 
Thirty-five years ago Morell Mackenzie stated that "it is not certain 
that any cases ever recover." His statistics showed that it reduced 
the average expectation of life to twelve or eighteen months, very few 
patients living more than two and a half years. But since phthisis 
has decreased in malignancy during recent years, patients suffering 
from laryngeal tuberculosis have also benefited and we now know that 
many recover. The lesion in the throat may heal, as has been found by 
careful studies of postmortem findings. 

The laryngeal lesion pier se only rarely kills the patient, and it has 
been stated that "consumptives never die from the larynx." This is 
wrong, of course, because we occasionally see a case of sudden death 
from asphyxia or edema of the glottis. The bulk of the patients with 
laryngeal complication die as a result of the severity of the pulmonary 
lesion, or inanition due to painful deglutition. In fact, when the 
larynx is extensively involved, producing dysphagia, dysphonia, etc., 
a fatal issue may be expected sooner or later. If the lesions in the lung 
and larynx are not sufficient to kill the patient he will die as a result 
of inanition. 

The milder subacute and chronic forms of laryngeal tuberculosis 
have a better outlook. Many heal spontaneously without any local 
treatment, The general treatment instituted often hastens recovery 



TUBERCULOUS ULCERATION OF THE INTESTINES 499 

from the laryngeal lesion. Very often the condition of the larynx goes 
hand-in-hand with the general condition of the patient, both improving, 
or aggravating, simultaneously. Others are benefited by local treat- 
ment. 

Gangrene of the Lungs. — This is an exceedingly rare complication 
of phthisis; it is more often found in cases of bronchiectasis, especially 
in old subjects. Considering that mixed infection is very frequent in 
phthisis, although the contaminating microorganisms are not respon- 
sible for most of the symptoms of the disease, it is surprising that 
putrefactive germs should but rarely take root in phthisical lungs. 
When occurring it is soon recognized by the fetid breath and expectora- 
tion. But not all phthisical patients with fetid sputum have gangrene 
of the lung. Sputum retained in tuberculous cavities may become 
fetid . In such cases the malodorous expectoration lasts only for a few 
days or weeks, and sooner or later assumes the odor usually met in 
phthisis. Its odor also is different from that of gangrenous sputum 
— it is of a sweetish and nauseating character, while in gangrene it 
is pungent and actually suffocating. The constitutional symptoms 
in gangrene are characteristic: The temperature is raised high, the 
patient passes into a septic state with acute asthenia, and succumbs 
rapidly. In afebrile cases of phthisis a sudden rise in the temperature, 
accompanied by fetid sputum, is a sure indication of complicating 
gangrene of the lung. 

Tuberculous Ulceration of the Intestines. — The frequency of intes- 
tinal ulcerations found at autopsies on tuberculous subjects would 
indicate that they are more frequent than they are diagnosed intra 
vitem. Thus Louis found ulcers in five-sixths of his cases; Bayle 
and Lebert, in two-thirds; Williams found at the Brompton Hospital 
postmortems in 81 per cent, intestinal ulcerations of a tuberculous 
nature; and Percy Kidd found them in 71 per cent. While they are 
responsible for the diarrhea in advanced phthisis in most cases, in 
many the looseness of the bowels is due to the toxemia, the toxic sub- 
stances in the blood being eliminated through the intestines, or swal- 
lowed sputum is the cause. Lardaceous disease of the intestines is 
very frequently responsible, while errors in diet, especially an excess 
of fat, or of milk, may induce diarrhea which is difficult to control. 

There may be eight, ten, or even twenty, motions a day, expelling 
loose, dark, or chocolate-colored, matter, exceedingly fetid, and it may 
contain small sloughs from the bowels. Quite often it is tinged with 
blood, but copious hemorrhages from the bowel are exceedingly rare. 
K. W. Lange, 1 looking for occult blood in the stools of tuberculous 
patients, found that tuberculous ulceration of the intestine may exist 
for a long time without giving rise to bleeding, and from his researches 
it appears that a negative result of a test for occult blood does not 
exclude ulceration of the intestine. John M. Cruice 2 says that when 

1 Ugeskrift for Laeger, 1917, lxxix, 1371. 
* Medical Record, 1913, Ixxxix, 471, 



500 



COMPLICATIONS OF PHTHISIS 



i 






hemorrhage occurs it is of grave prognostic significance. The first case of 
this kind was reported by Tonnelle in 1829. In 1892 Guyenet could 
find only 15 cases in medical literature and Cruice found 10 additional 
cases in 1913. Although the prognosis is very grave in intestinal hemor- 
rhage, L. S. Peters, Bullock, and Bonney report cases that recovered. 

One characteristic of tuberculous diarrhea is its persistence. It 
may be checked by proper dietetic and medicinal treatment, but no 
sooner is this omitted than it reappears. With the diarrhea the 
emaciation proceeds at a rapid pace and they usually foreshadow 
quick relief from the suffering. I have seen patients who had been 
gaining, lose within one week all they gained in months, and within 
two to four weeks they were reduced to mere skeletons. 

Diagnosis. — It is very difficult to say with certainty whether a diar- 
rhea in a consumptive is due to toxemia or to intestinal ulceration. 
Tenderness is often found in the right iliac fossa, but it may be all 
over the abdomen, or any part of it. J. Walsh 1 made a thorough 
study of the symptomatology of intestinal ulceration, correlating 
it with autopsy findings in 100 cases at the Phipps Institute. The 
usual symptoms relied on — diarrhea, and abdominal pains, tender- 
ness and rigidity, especially in the region of the ileocecal valve — were 
carefully studied. He found that singly these symptoms add little 
or nothing to the diagnosis of intestinal tuberculosis, nor do any two, 
or all four when found in the same patient, because they may be 
encountered in cases in which the autopsy shows no ulcerations in the 
intestines, and the reverse. The presence of an ischiorectal abscess in 
an advanced case adds to the probability of intestinal ulcerations. 
Nor has he found any relation between the presence or absence of 
albumin in the urine, or the results of the diazo-reaction, or indican in 
the urine, and intestinal ulceration. He concludes that the diagnosis 
of intestinal tuberculosis cannot be made with the slightest degree of 
certainty from our present known symptoms, and since the condition 
carries with it such an unfavorable prognosis, he advises that it is best 
that the diagnosis should not be made, so that the patient will have a 
better chance for hopeful treatment. 

While the outlook for healing of these ulcers is remote, yet it is 
possible. Amenomiya 2 shows that regeneration and healing are possible 
even without scar formation, but the muscular coat is never regen- 
erated. 

Peritonitis. — The pathogenicity of tuberculous peritonitis as a 
complication of phthisis is no more the disputed problem which it 
was formerly. Considering the frequency of bacillemia in phthisis, 
it is clear that the blood may bring tubercle bacilli to the peritoneum 
just as readily as to other serous membranes. It is not so frequent a 
complication as is laryngeal or intestinal tuberculosis, but it appar- 
ently occurs more often than is suspected at the bedside, and we are 



1 National Assn. Study and Prev. Tuberc. 

2 Virchows Archiv., 1910, cci, 231. 



1909, v, 217, 



PERITONITIS 501 

at times surprised to find it at the autopsy when, intra litem, even in 
carefully watched cases, it was not suspected. 

Authors disagree as to its frequency in phthisis. Munstermann 1 
found it in 5 per cent, of cases; Borschke 2 in 16.17 per cent. In his 
autopsy material P. Horton-Smith Hartley found it in only 3.4 per 
cent, of cases. Perforation of tuberculous ulcers of the bowels was 
observed in 3 cases out of 263 autopsies, or a percentage of 1.1, the 
perforation in each of the instances occurring in the ileum. It appears 
to be very frequent in acute miliary tuberculosis, but in chronic pul- 
monary tuberculosis it is less often encountered. While in many cases 
the infection of the peritoneum can only be explained by assuming 
that the bacilli were brought there by the blood, in a considerable 
number they may travel by way of the lymphatics from the pleura, 
the pericardium, from the mesenteric lymph glands and above all by 
contiguity from infiltrated Peyer's patches and ulcers of the intes- 
tines. They may also come by contiguity from tuberculous lesions 
of the urogenital system, especially from the adrenals, which are often 
the seat of tuberculous changes in phthisis. 

Symptoms. — We meet mainly with two forms of this complication : 
dry, adhesive, and moist or exudative, both of which may be acute or 
chronic. During the course of phthisis the acute form, in the clinical 
sense, is usually due to perforation of an intestinal ulcer, or, more rarely, 
a pyothorax breaking into the peritoneal cavity, when it may produce 
suppurative peritonitis. In one case, in which during life the condition 
was not even suspected, I found at the autopsy a minute opening 
through the diaphragm permitting leakage of the pus from a pyo- 
pneumothorax. Fen wick 3 maintains that in some cases there may be 
premonitory symptoms, viz., pain for a few days before actual per- 
foration takes place from a tuberculous intestinal ulcer; in others 
there may be bilious vomiting, the abdomen is distended, and hyper- 
resonant on percussion. These premonitory symptoms are obviously 
due to local acute peritonitis. The actual perforation may occur dur- 
ing straining at stool, during an attack of vomiting or retching, or 
altogether while the patient is at rest. Some patients feel acute 
pain or a sensation as if something had given way in the abdomen. 
Collapse ensues and within a few hours or days the patient succumbs 
to cardiac failure. Some recuperate from the shock but they suc- 
cumb within a few days to the symptoms of acute peritonitis, or more 
rarely to exhaustion . 

The chronic form may be overlooked because it often runs its course 
symptomless. The patient may complain of abdominal pain, vomit, 
and have diarrhea, but these symptoms are very frequent during the 
course of phthisis without any peritoneal complication. On the other 
hand, there are cases with peritonitis in which all these symptoms are 

1 Die Bauchfelltuberkulose, Munich, 1890. 

2 Vir chows Archiv., 1892, cxxvii, 121. 

3 Dyspepsia of Phthisis, London, 1894, p. 176. 



502 



COMPLICATIONS OF PHTHISIS 



I 




lacking. The ascitic form is exceedingly rare in phthisis, though now 
and then we meet with a case in which the abdomen is filled with 
fluid. To be sure, there are many cases with exudates, but they usually 
escape detection until they assume large dimensions. 

It must be considerable to be discoverable by percussion. F. 
Mueller experimented on cadavers and found that in children under 
one year of age 200 c.c. of fluid in the peritoneum may be discovered 
in the peritoneum by percussion. In adults only two liters gave per- 
cussion signs; 1.5 liters gave some dulness in the dependent portions, 
while 1 liter could not be detected. In the living, Mueller, Sahli, 
and others state, conditions are more favorable, because of the elas- 
ticity of the abdominal wall and viscera. Small effusions may be 
detected in the knee-chest position. 

The adhesive form is characterized by the formation of adhesions 
and cicatricial contractions of the mesentery and gluing together loops 
of the gut are very frequent. Especially frequent are adhesions of the 
peritoneum to the liver and spleen. The adhesions and cicatricial 
contractions, at times, produce incomplete stenosis of the intestine 
with resultant persistent constipation and uncontrollable vomiting. 
Colicky pains, increased by pressure and on movement, may be 
observed. In these cases the emaciation may be extreme, despite 
the fact that the local lesion in the lungs is not extensive nor very 
active. When the inflammation in the peritoneum is limited and 
circumscribed, which is not infrequent, the pain may be localized 
at one point. It is noteworthy that fever may be absent, but in most 
cases of active phthisis, pyrexia due to the lung lesion is so frequent 
that it cannot be utilized for diagnostic purposes as to the presence 
or absence of a peritoneal complication. On the other hand, when the 
lesion in the lung is quiescent or latent, the complicating peritonitis 
may pass an apyretic course. In many cases there is diarrhea due to 
intestinal catarrh or, more frequently, to ulcerations of the intestine. 

As was already stated, many cases run their course painlessly. When 
copious, the exudate is easily detected by the usual physical signs. 
In others it is encysted because of plastic fibrinous formation. Thor- 
mayer 1 described physical signs which he considers characteristic of 
tuberculous and carcinomatous peritonitis. He found that tympany 
is very frequently elicited on the right side of the abdomen, while on 
the left side a dull note is elicited by percussion. He explains this 
phenomenon on anatomical grounds: The mesentery in the right 
side usually contracts more than in the left, and thus intestinal coils 
are apt to be drawn to the right by the shrinking mesentery; tympany 
is then elicited over these distended intestinal coils. It is, however, 
an inconstant symptom and if it occurs at all, it is discerned late, after 
the organization of the exudate. 

At times we may, on palpating the abdomen, feel some crepitation, 



Ztschr. f. klin. Med., 1884, vii, 378. 



APPENDICITIS 503 

and in some cases I have even heard friction sounds while auscultating 
with the stethoscope. On rare occasions, tumor-like masses are 
palpable in the abdomen. When localized in the right side they may 
simulate appendicitis. In one case under my care repeated attacks of 
pain in the right lower part of the abdomen, constipation, and even 
rigidity of the rectus muscle exquisitely simulated appendicitis. But 
later when a tumor was palpable the condition was cleared up. In 
another case under my care symptoms not unlike those of intestinal 
obstruction were present in a woman with tuberculous pleurisy, and 
the advisability of operative interference was seriously considered, 
but the patient recovered. It appears that tuberculous cicatrices 
causing narrowing of the gut may stretch, and thus relief ensues. This 
is also true of cicatrices of the intestinal wall caused by healing tuber- 
culous ulcers. 

Appendicitis. — Considering the large number of tuberculous persons, 
it is clear that some should develop appendicitis, independent of the 
tuberculous process in the lungs, or even the intestines. It is, however, 
a fact that on rare occasions we meet with distinct tuberculous inflam- 
mation of the appendix. The symptoms are the same as in the classical 
cases due to other causes. When complicating intestinal tuberculous 
ulceration or tuberculous peritonitis, the diagnosis is difficult and of 
little significance, because the prognosis of the pulmonary and intestinal 
conditions is grave, irrespective of the treatment instituted for the 
appendicular trouble. The frequency of appendicitis among tuber- 
culous is, in the experience of the writer, not much above that in non- 
tuberculous persons. H. M. Kinghorn 1 found among 727 tuberculous 
patients 43 cases of appendicitis, or 5.9 per cent. The percentage was 
higher among males (6.8 per cent.), than among females (4.6 per cent.). 
This is a much higher percentage than has been encountered by the 
writer. In fact, I am inclined to agree with Gerald Webb 2 to the effect 
that " operations are too readily undertaken in these patients, too often 
for mistaken diagnoses." He points out that during six years several 
hundred cases of pulmonary tuberculosis had passed through his hands 
at the Cragmor Sanatorium. He had not felt justified in advising the 
removal of the appendix in any case. He had no results to prove that 
this advice had been to the detriment of any patient. This has been 
the experience of the writer at the Montefiore Hospital, as well as in 
private practice. 

Patients suffering from diaphragmatic pleurisy often have pain in 
the right iliac fossa, which at times simulate the symptoms of appen- 
dicitis. This may be the case in acute pleurisy, but those with chronic 
pleurisy, not uncommon in tuberculous, have pain in the right side of 
the abdomen. It is not rare that appendicitis is diagnosed, and even 
operation performed. In treating tuberculous patients these points 
are to be borne in mind (see p. 423). 

1 Jour. Am. Med. Assn., 1916, lxvii, 1842. 

2 Tr. Nat. Assn., Study and Preven. Tuberc. 1917, xiii, 202. 



504 COMPLICATIONS OF PHTHISIS 

Tuberculous Meningitis. — Many phthisical patients show cerebral 
symptoms a few days before death, but at the autopsy no changes 
are found within the cranium. In these cases the diagnosis is not 
important because the seriousness of the condition is evident from the 
other symptoms. The problem of the presence or absence of menin- 
geal implication in phthisis has, however, a great prognostic value in 
cases showing a tendency to quiescence or cure, and the occurrence 
of symptoms suggestive of tuberculous meningitis is more than dis- 
quieting. 

The onset of this complication is usually insidious. For some days, 
at times for more than two weeks, the patient complains of headache, 
is irritable and fretful and vomits most of the food and drink given him. 
Tuberculous patients only rarely suffer from headache, unless pyrexia, 
or some nasal or gastro-intestinal trouble is responsible. If a persist- 
ent headache cannot be explained as due to some other cause, meningitis 
is to be thought of. If there is also vomiting the diagnosis is greatly 
supported, though not conclusive. There are also noted early confu- 
sion of ideas, impaired memory, photophobia, defective vision, drow- 
siness and somnolence which may pass into coma, or convulsions. 

The pulse is rather slow in most cases, though at times we meet 
with a case in which it is accelerated . But it is very frequently irreg- 
ular. The temperature may be high, though this is rare. In most 
cases it does not exceed 102° F. Constipation is a frequent symptom, 
and during the last days retention of urine may occur. But these 
are not constant symptoms. Patients with diarrhea may continue with 
loose stools and, in the later stages, involuntary evacuation of urine 
and stools may occur. 

In most of my cases many of these symptoms were noted early but 
they were not continuous, occurring one day and disappearing the 
next, to reappear again. This intermittency is a very important point 
in the diagnosis of obscure cases. Very early there is often noted a 
complete change in the character of the individual. The hopefulness 
and euphoria disappear: the patient becomes disinterested in things 
which were vital to him before. This passes into drowsiness, and he 
refuses to answer questions, though when waked up he recognizes 
the person addressing him. Some act as if they were under the influ- 
ence of alcohol, and in one case we suspected that the patient had 
imbibed whisky, and rebuked him for violating the hospital rides. 
Occasionally hysteria will simulate meningitis exquisitely. Kernig's 
sign is present in most cases, though in some it is lacking at the early 
stage. At the end Cheyne-Stoke's breathing, paralysis of some cranial 
nerves, optic neuritis, and convulsions may occur. 

In most of the cases under my care lumbar puncture has not been of 
material assistance for early diagnosis. Very often the fluid is cloudy, 
shows an excess of lymphocytes, and is rarely sanguineous. But it 
must be mentioned that an excessive number of lymphocytes is not 
always a sure sign of tuberculous meningitis. In a large proportion 



CARDIAC COMPLICATIONS 505 

of cases the cerebrospinal fluid shows no change in its cytology, though 
the course of the disease, and the autopsy, leave no doubt that there 
was meningitis. In some, though not in all, tubercle bacilli may be 
discovered in the cerebrospinal fluid. Usually the fluid is under high 
pressure, but I have seen cases in which it squirted out forcibly, yet 
the subsequent course showed that there was no meningitis. 

Patients with this complication do not last over two weeks, as a rule, 
though I have seen some who have lasted more than a month. A fatal 
prognosis should be given whenever meningitis is diagnosed; the few 
cases of recovery which have been reported may be considered medical 
curiosities. 

Cardiac Complications. — We have shown that phthisis only excep- 
tionally develops in persons suffering from chronic endocarditis, except- 
ing in those with congenital heart disease (p. 102). But endocarditis 
may develop during the course of phthisis, either due to complicating 
rheumatic disease or any other accidental septic process, as tonsil- 
litis, etc. The verrucose excrescences on the cardiac valves often 
found at autopsies on phthisical subjects are usually caused by other 
microorganisms, though Heller, Leyden, Benda, Tripier, and others 
maintain that tubercle bacilli may be responsible in some cases. 

Myocarditis. — In most cases heart failure in advanced phthisis is 
due to myocarditis, with dilatation of the right heart; to tuberculous 
pericarditis and also to dilatation with cardiac displacement. Like 
in other chronic, cachectic, and exhausting diseases, the myocardium 
partakes in the atrophy of the muscular system and gives way from 
sheer exhaustion. In fibroid phthisis and the pleural forms of chronic 
phthisis, the induration in the lungs interferes with the circulation, 
and heart failure of variable degree is the result. Before the onset of 
decompensation, hypertrophy of the right ventricle is quite common, 
especially in fibroid phthisis. 

Pulsations in the epigastrium and accentuation of the second pul- 
monic sound reveal this condition. However, accentuation of the 
second pulmonic sound may be present without hypertrophy when 
the left lung is retracted through infiltration or shrinkage and reveals 
the left heart. The constitutional symptoms of heart failure — dyspnea, 
edema, etc. — may be quite marked. 

Pericarditis.— Pericarditis may occur during the course of chronic 
phthisis. Several cases of primary tuberculous pericarditis have been 
reported. In chronic phthisis the pericardial sack may be implicated 
by tuberculous processes of the pleura or mediastinal glands. Adhe- 
sions between the pleura and pericardium are often found and with 
the shrinkage of the affected lung the heart is pulled out of its normal 
position, as has already been described. 

Very often we meet with acute pericarditis in phthisis and pleuro- 
pericardial friction sounds may be audible. The symptoms and signs 
of adhesive pericarditis are not rare in chronic phthisis— systolic retrac- 
tion of the chest wall at the apex, engorgement of the veins in the 



506 COMPLICATIONS OF PHTHISIS 

neck, disappearance or weakening of the pulse during inspiration, 
pulsus paradoxus, etc. 

On very rare occasions we meet with acute pericarditis coming on 
suddenly with pain in the cardiac region, dyspnea, cyanosis, cardiac 
irregularity, etc. In one case under my care the symptoms simulated 
pneumothorax. Careful examination of the heart, however, clears up 
the case. The cardiac dulness is increased, friction sounds are audible, 
the apex beat disappears with the effusion. The pericardium may 
also be implicated in cases of pneumothorax, producing pneumoperi- 
cardium, as has already been mentioned. 

Phlebitis and Thrombosis. — Although occurring quite frequently 
during the course of phthisis, phlebitis and thrombophlebitis are only 
rarely mentioned as complications of this disease. Older clinicians, 
as Hoffmann in 1740, and after him Hunter, Louis, Trousseau, and 
others have mentioned it, and Cursham wrote in 1860 on "Causes 
of Obstruction of the Veins of the Lower Extremities Causing Edema 
of the Corresponding Limb and Occurring in Phthisical Patients." 
Most writers are inclined to attribute them to the tuberculous toxemia, 
while others have found in them an instance of marantic thrombosis. 
But recently Gustav Liebermeister, 1 in a thorough clinical and patho- 
logical study of the subject, attributes them to the direct action of the 
bacilli on the bloodvessels, finding as he does that nearly all tubercu- 
lous patients have a bacteremia. Haushalter and Etienne, Vaquez, 
Sabrazes and Mongour, Chantemesse and Widal, Lesne and Revaut, 
Liebermeister, and others have found virulent tubercle bacilli in such 
thrombi. In cases under my care no tubercle bacilli could be found in 
the thrombi microscopically or by inoculation of animals. 

Phlebitis and thrombosis in phthisis usually occur in the femoral 
vein, though at times we meet with cases in which the vena cava, the 
innominate, jugular, subclavian, or renal veins are affected or even 
the cerebral sinuses. The frequency of this complication is given by 
P. R. Dowdell 2 as 30 among 1300 consumptives, or 1.5 per cent. H. 
Ruge and Hierokles 3 found it nineteen times among 1778 cases of 
pulmonary tuberculosis, or 1 per cent. In my experience it appears 
to be even more frequent in advanced and active cases of phthisis. 
P. Horton-Smith Hartley found thrombosis of veins in 2.6 per cent, 
of 263 cases which came to autopsy. In males the percentage was 
but 1, while in females it was 6.6. Ethan A. Gray observed thrombo- 
phlebitis as a complication of phthisis seven times in 1400 cases at the 
Chicago Fresh Air Hospital: 3 in men and 4 in women. 

Phlebitis is very often found in the veins of the upper or lower 
extremities, especially in very active cases running high fever. Mostly 
the medium-sized or small veins are affected. Clinically, the thicken- 
ing of the veins of the upper extremities are more easily recognized by 

1 Virchows Archiv., 1909, cxcviii, 332. 

2 Am. Jour. Med. Sc, 1893, cv, 641. 
3 Berl. klin. Wchnschr., 1899, xxxvi, 73. 



PHLEBITIS AND THROMBOSIS 507 

palpation because of the lesser thickness of the muscles and adipose 
tissue. The affected veins are tender to the touch and also painful on 
motion of the limb. Edema of the extremities is exceptional in simple 
phlebitis, though in some cases it may occur. The phlebitis may 
disappear, to reappear again and in most cases it is persistent till 
thrombosis also occurs, or till the fatal issue of the case. In fact, 
phlebitis is an ominous complication. A thrombus may develop and 
it may soften and be carried by the circulating blood to distant organs, 
producing pulmonary embolism or infarction. It may organize and 
remain as a firm, thick cord. Hirtz 1 described cases of phlebitis and 
thrombosis occurring during the incipient stage of phthisis, or even 
preceding the actual onset of the disease, especially in chlorotic girls. 

Thrombosis of the Femoral Veins. — Thrombosis occurs most frequently 
in the femoral vein but, as was pointed out by Dowdell, usually the 
popliteal vein is found to contain a clot of older date, while in some 
the saphenous vein is plugged and rarely the superficial veins of the leg 
and thigh, as well as the main trunk from the tibial vein upward, are 
thrombosed. Dowdell, Ruge and Hierokles, Liebermeister, and 
others have also found thrombosis of the uterine and brachial veins, 
the prostatic plexus, and embolism of distant arteries is said to be not 
uncommon. As is the case with phlebitis, thrombosis is found mostly 
in far-advanced but acutely running cases and is usually the precursor 
of a fatal issue. 

The most important symptom is edema of the affected limb. The 
onset is usually slow and insidious, the swelling coming on gradually. 
Pain is often felt for a few days after the onset of edema, but in many 
cases this is lacking. When present it is mainly felt in the popliteal 
space where tenderness may be elicited. Inasmuch as practically all 
these patients have symptoms of active phthisis, the temperature 
is not an aid in the diagnosis — it is continuous or hectic, as the case 
may be; the onset of the thrombosis, edema, etc., has hardly any 
influence on the pyrexia. In some cases under my care there were 
disturbances in sensation of the. affected limb, which was cold, numb, 
or tender. In one case the pain was excruciating and morphine alone 
was effective in relieving it in part. When the deeper veins of the 
muscles are plugged, which is not rare, there may be severe pain and 
hyperesthesia of the calf of the affected leg. Diagnosis may be difficult 
at first, but as soon as the edema appears, the cause is clear. In some 
cases the thrombus in the affected vein is so thick as to be palpable. 
I have many times been able to palpate the femoral and crural veins 
as thick, firm cords tender to the touch. 

Diagnosis. — In most cases the diagnosis of thrombosis and phlebitis 
is rather easy. It is to be differentiated from edema of the extremities 
common in phthisis and due to cardiac and renal insufficiency, and 
from cachectic edema which is frequently seen in the terminal stages 

i Semaine Meclicale, 1894, xiv, 274. 



508 COMPLICATIONS OF PHTHISIS 

of this disease. Thrombosis always begins in one extremity and is 
confined to it, or marked on one side when fully developed. It is 
tender to the touch along the course of the veins and not necessarily 
over the edematous skin. The dilated superficial veins may at times 
contain clots. On the other hand, edema due to cardiac or renal 
disease is accompanied by signs and symptoms of these conditions, both 
lower extremities are affected by the swelling, and the tenderness along 
the course of the veins is lacking. Cachectic edema occurs on both 
sides, is painless and subsides when the patient is kept in the recum- 
bent position for some time. At times intra-abdominal pressure on the 
common or external iliac vein or on the femoral may produce edema 
of one extremity not unlike that of thrombosis. The same condition 
may occur, though very rarely, in the upper extremity when intratho- 
racic pressure is exerted by enlarged glands in the thorax on the main 
trunks of the veins. But careful examination will usually reveal the 
tumor or the glands which are responsible. 

Thrombosis of the Jugular Vein. — Thrombosis causing edema of the 
upper extremity is very rare, but it does occur. Two cases have come 
under my observation. Humphrey 1 reported such a case in 1859; 
Lesague 2 observed in 1870 a case of phthisis complicated by the for- 
mation of a thrombus in the external jugular, subclavian, and humeral 
veins. Ten days after the appearance of the thrombus it was com- 
pletely softened and all symptoms of phlebitis disappeared. But 
in all other cases reported, death supervened within a couple of weeks 
after the establishment of thrombosis. The symptoms are edema, 
pain, etc., of the upper extremity. In 1904 Charles J. Aldrich 3 collected 
from the literature 9 cases of this complication of phthisis and reported 
1 of thrombosis of the left internal jugular with extension through 
the subclavian down the axillary into the basilic veins. Two weeks 
later a like thrombus appeared in the right side and extended to the 
veins of the arm. Death was due to cerebral sinus thrombosis from 
extension of the thrombus in the right internal jugular vein. In one 
of my cases thrombosis of the right internal jugular vein occurred in 
a patient with a spontaneous pneumothorax. 

Prognosis of Thrombosis. — The prognosis is fatal in nearly all cases 
because of the severity of the tuberculous process, occurring as it does 
mainly in rapidly advancing cases of phthisis. Death may be due to 
secondary emboli which cause sudden death. Excepting Lesague's 
case mentioned above and Ethan A. Gray's case, I have not heard of a 
patient with phthisis complicated by thrombosis of the upper or lower 
extremity surviving two months; they usually succumb within one 
month. 

Urogenital Tract. — Of other complications occurring more or 
less often during the course of phthisis may be mentioned tuber- 

1 British Med. Jour., 1859, 582, 601, 619, 650. 

2 Gaz. Med. de Paris, 1879, i, 649. 

3 New York Med. Jour., 1904, lxxix, 442. 



TUBERCULOUS ULCERATIONS OF MUCOUS MEMBRANES 509 

culosis of the urogenital tract. We have already mentioned that 
albuminuria is not uncommon in phthisis. In far-advanced cases, 
nephritis is quite frequent and we may have most of the symptoms 
of this disease, especially edema, anasarca, etc., and even uremia, which 
is at times difficult to differentiate from tuberculous meningitis. In 
many of the advanced cases we may also note symptoms due to amyloid 
disease of the kidneys : Abundance of secretion of urine of low specific 
gravity containing hyaline casts and albumin in large quantities. But 
in this form of nephritis dropsy is infrequent. I have been struck 
with the fact that in most cases in which there is considerable albumin 
in the urine and dropsy, the temperature drops down to near normal 
and very often the activity of the process in the lung diminishes. 
The prognosis is, however, not improved. 

In some cases tuberculosis of the kidneys supervenes and also of the 
bladder, seminal vesicles, vas deferens, and epididymis. Tuberculosis 
of the kidneys is very difficult of diagnosis in its early stages. Finding 
acid-fast bacilli in the sediment of the urine is not sufficient to base a 
diagnosis in my experience, excepting when the specimen has been 
obtained by catheterization of the ureter. Even so there have been 
reported cases in which tubercle bacilli were found microscopically and 
by inoculation into animals, yet the autopsy, or the kidney removed by 
operation, showed no tuberculous lesion. This is a fact which should 
never be lost sight of in doubtful cases. I have seen cases in which 
tubercle bacilli were thus found yet the patient improved without 
operation. Patients with tuberculous pyelitis suffer usually from 
lumbar pain of a dull character, have pus, albumin and blood, renal 
epithelium, and even caseous debris in the urine. I have seen cases 
in which the pain occurred in paroxysms and it was difficult to 
differentiate from that of renal colic due to stone. 

Terminal Edema. — In a large proportion of tuberculous patients 
edema, general or local, appears a few days, or weeks, before the fatal 
termination of the case. The edematous swelling is mainly seen around 
the joints of the lower extremities; but at times it involves the whole 
body. The origin of this edema is not known definitely Some are 
inclined to attribute it to nephritis, but it is met with in cases in which 
the autopsy shows that the kidneys remained in good condition. 
Others state that it is due to myocardial degeneration, especially 
to dilatation of the right ventricle. Charles W. Mills 1 and John T. 
Henderson found a characteristic picture by Mosenthal's test, with a 
marked decrease in water and sodium chloride elimination. 

Tuberculous Ulcerations of Mucous Membranes. — We have already 
pointed out that despite the fact that so much of tuberculous sputum 
passes through the mouths and lips of phthisical subjects, ulcerations 
of these parts are extremely rare. But it appears that tuberculous 
ulceration of the tongue is more frequent than is generally appreciated, 

iAm. Rev. Tuberc, 1917, i, 573, 



510 COMPLICATIONS OF PHTHISIS 

James R. Scott has recently drawn attention to this fact. At the 
Montefiore Hospital I see about eight or ten cases a year. These 
ulcers may appear fissured, granulomatous, or papillomatous; in many 
cases they are located on the dorsum of the tongue but very frequently 
also on the tip, the sides and, rarely, on the frenum. I have seen some 
with ulcers of the soft palate, and very rarely on the posterior wall 
of the pharynx. In a recent case under my care there were ulcers 
on the tongue, one on the tip and two on each side. 

In most cases the diagnosis is clear, occurring as they do in patients 
with pronounced tuberculous lesions in the lungs and perhaps the 
larynx. But, at times, they may be found in a patient without very 
active symptoms of phthisis, and must then be differentiated from local 
manifestations of syphilis, carcinoma, and epithelioma. A careful ex- 
amination of the chest will clear up the case, because these ulcerations 
are, almost without exception, secondary to tuberculosis in the lung. 
A specimen removed and examined microscopically may show the 
characteristic tuberculous changes or tubercle bacilli. 

Purpura. — I have seen several cases of purpura hemorrhagica compli- 
cating advanced phthisis. Petechia are very frequent in many cases, 
but true purpura hemorrhagica with extensive ecchymoses scattered 
over the limbs may occur, and there may be simultaneously hemor- 
rhages from some of the mucous membranes — true purpura hemor- 
rhagica. In 3 out of the 4 cases seen by me recently there were also 
albuminuria and hematuria, and the patients succumbed shortly 
after the appearance of the purpura, and I am inclined to agree with 
John M. Cruice 1 to the effect that the occurrence of purpura, espe- 
cially the hemorrhagic form, in the course of tuberculosis is always a 
grave symptom. 

Its etiological relation to tuberculosis is doubtful. Some authors 
are inclined to see in the tubercle bacillus a cause of the purpura, but 
the fact that it is so extremely rare in phthisical subjects shows that 
when the two diseases occur in the same subject, it is in all probability 
a coincidence. I believe that Cruice 's observation that after an 
attack of purpura physical examination will reveal a more advanced 
condition of the lesion does not at all prove that the hemorrhages into 
the skin were directly of a tuberculous character; it by no means 
excludes the chances of their being a coincidence. 

Superficial Cold Abscesses in the Chest Wall. — Though these ab- 
scesses are not very uncommon in tuberculous subjects, they are only 
rarely mentioned in monographs on the subject of tuberculosis. Their 
relation to phthisis was first pointed out by Leplat in 1876. Other 
French authors, notably Gaujot, Duplay, Yerneuil, Charvot, and others 
then described them in detail. Three varieties have been mentioned, 
one arising from the cellular tissues, one from the periosteum of the 
ribs, and a third of deep origin from the bone. Gaujot described these 

*Am, Jour. Med. §q„ 1912, cxliv, 875. 



SUPERFICIAL COLD ABSCESSES IN THE CHEST WALL 511 

abscesses as in front of the ribs, behind the ribs, and of the shirt-stud 
variety, in which a superficial and deep abscess communicates through 
an intercostal space. 

S. Souligoux, Peron, Villar, Paget, and more recently Samuel 
Robinson, 1 show that these abscesses are of pleuropulmonary origin. 
Robinson, with considerable a>ray experience, shows that "the time- 
worn custom of regarding such lesions as due solely to a necrotic rib is 
unquestionably a fallacy." Erosion and even necrosis, particularly 
of the posterior surface of the rib, are not uncommon, but this is purely 
incidental. It usually follows old tuberculous pleurisy, but may be 
found in pulmonary cases. The tubercle bacilli apparently invade the 
chest wajl through the lymphatics which may be found in old adhesions 
of the pleura. These abscesses have been found, on rare occasions, to 
drain by breaking through a tuberculous lung. They are analogous to 
the abscesses found often in the vicinity of the incision for empyema of 
tuberculous origin. 

On the chest wall, along the line of insertion of the diaphragm, 
particularly anteriorly, or in the lower axillary region, there is noted a 
circumscribed swelling, the size of a pigeon's or a hen's egg, painless and 
fluctuating. There is usually no surrounding inflammatory induration, 
and only later the infected area becomes red and somewhat tender. 
When incised a moderate amount of liquid, curdy pus is eliminated, 
but healing is slow: In most cases a fistula is left which persists for 
months; or an ulcer remains which keeps on discharging pus for a 
similar period. Very often the fistula or ulcer is located over a rib, 
the periosteum of which is implicated. In many cases healing finally 
takes place leaving an ugly red scar. 

The diagnosis is at times difficult — there is a question whether it 
is not an empyema pointing on the chest wall, particularly when 
there are physical signs of a lung lesion or thick pleura elicited in the 
same area. A careful consideration of the history and course of the 
trouble, however, clears up the diagnosis. 

1 Tr. Nat. Assn., Study and Preven. of Tuberc, 1917, xiii, 170. 



CHAPTER XXX. 
PROGNOSIS IN PULMONARY TUBERCULOSIS. 

The Curability of Phthisis.— Laennec, the first physician to make a 
scientific study of the pathology of phthisis, pronounced it an incurable 
disease. It appears, however, that this keen clinician recognized that 
many cases do recover. He said : " The cure of phthisis is not beyond 
the powers of Nature, but it must be admitted, at the same time, that 
art possesses no certain means of attaining this end." 

The observations of physicians all through the nineteenth century 
have clearly shown that phthisis is not invariably fatal, despite the 
fact that the treatment applied during the first half of the nineteenth 
century should have killed most of the curable cases, according to 
our understanding of the pathology and therapy of the disease. Still, 
Flint reported 670 cases observed during a period of thirty-four years 
and the proportion of cases cured or arrested was not much below 
that which we attain at present. Thomas J. Mays 1 compiled statis- 
tics of Flint's 670 cases and Williams's 1000 cases observed for twenty- 
two years, and compared the results with Trudeau's 1060 cases under 
observation for seventeen years. The percentages of recoveries and 
survivals are about the same, or rather in favor of Flint's and Williams's 
cases. 

At present we have sufficient and uncontrovertible proof that tuber- 
culosis is curable in all its stages. Experience while making autopsies 
shows, in fact, that it is the most curable of chronic diseases, consider- 
ing the enormous number of persons who show healed, or quiescent, 
tuberculous lesions in the lungs when examined after death. And the 
lesions discovered are often such as to indicate that the process was 
quite extensive at the time of its activity. 

Importance of Prognosis. — There is no need of elaborating on the 
importance of prognosis in the practice of medicine. It is always 
significant and, in the case of tuberculosis, it is, at times, even more 
important than diagnosis. Indeed, most patients come with ready- 
made diagnoses and all they want to know is the ultimate outlook. 
"Will he recover?" is one of the first questions after the patient and 
his friends are told that there is a tuberculous lesion. " If so, how long 
will it take till he recovers?" Moreover, it is important to be ready 
to answer whether the patient, after recovery, will be able to resume 
his occupation, and whether there is danger of relapse. In case of an 
unfavorable prognosis it is often asked, "How long will the patient 
last?" 

J Ne^y York Med, .Tour-, 1914, c, 70. 



VARIOUS FORMS OF PULMONARY TUBERCULOSIS 513 

We cannot answer all or most of these questions in the average 
case with a high degree of certainty. As J. Mitchel Bruce 1 says: prog- 
nosis in tuberculosis u is always a difficult and often a disappointing 
proceeding. With all the facts of a case in our possession the conclu- 
sion we reach proves .too frequently to be false. Indeed, paradoxical 
as it may appear, we fail in prognosis most often because of the very 
number, variety, and different character of the facts that we discover. 
Each of our observations has its own prognostic value, and most of 
them have a different value in different instances and at different times. 
We meet with an extraordinary, variable, and therefore uncertain, 
course of the pathological process from month to month. No disease 
is so difficult to deal with in this connection, and we have to confess 
that we too often find ourselves changing our forecast in both directions 
from time to time." The extreme difficulty of prognosis in phthisis 
has been best expressed by the one who said that he who attempts to 
forecast the outlook may be sure of one thing only and that is that he 
will be mistaken. 

The difficulties are, however, not insurmountable in many cases, 
and we can estimate the prognosis of the average patient in any stage 
of the disease with a certain degree of exactitude. But in order to 
do this, we must take into consideration all available facts which may 
have any bearing on the course of the disease. 

Elements of Prognosis in Phthisis. — The notion that this disease is 
curable only in its incipient stage is one of the half-truths which have 
gained universal credence because of tradition. There are so many 
exceptions as to almost nullify this ancient dictum. We have already 
shown that it is fallacious to classify phthisis into three or four stages, 
and to say without reservation that in the 'first stage it is curable; 
in the second stage the chances of recovery are considerably dimin- 
ished, while in the third stage it is incurable. There are "incipient" 
cases which hate no chance, irrespective of the treatment applied; while 
there are many in the third stage ivhose chances of survival and even of 
efficiency are excellent. For this reason we shall not discuss the prog- 
nosis of phthisis according to the stages of the disease. 

The elements of prognosis in phthisis reside in the following factors: 
(1) The form of the disease; (2) in a given form of the disease, the 
activity of the process as revealed by the constitutional symptoms 
and physical signs; (3) the presence of complications; (4) the extent 
of the lesion in the lungs; and (5) the economic condition of the 
patient. 

Prognosis in the Various Forms of Pulmonary Tuberculosis— We 
have seen from our study of the symptomatology of phthisis that the 
form of the disease has a greater influence on the ultimate outlook than 
the extent of the lesion or even the activity of the process. Thus, 
in the pulmonary form of miliary tuberculosis, the chances of recovery 

1 Lancet, 1913, i, 591. 
33 



514 PROGNOSIS IN PULMONARY TUBERCULOSIS 

are nil. The patient will die irrespective of the treatment applied. 
In acute pneumonic phthisis the prognosis is very unfavorable, the 
only hope we may entertain is that the disease will take a turn to the 
better, and pursue the course of chronic phthisis. This happens on 
rare occasions, but it should not be expected in the average case. In fact, 
we may say that the prognosis is decidedly bad in these cases. Patients 
with acute phthisis usually last as many weeks or months as those with 
chronic phthisis last years. 

On the other hand, taking the other extreme, abortive tuberculosis, 
we find that the prognosis is favorable under all circumstances. Prac- 
tically all patients recover; the vast majority without even knowing 
that they have been tuberculous; or when the disease has been diag- 
nosticated there often remains a lurking suspicion that it was a false 
alarm, even if tubercle bacilli were discovered in the sputum. 

In fibroid phthisis the prognosis is very good indeed, so long as there 
is no fever. The dyspnea and discomfort which this disease causes 
for years are bearable by the average patient, But as soon as fever 
makes its appearance and persists for some time, the prognosis is 
that of chronic phthisis, which will soon be discussed. 

The influence of the patient's age on prognosis has already been 
discussed in the chapters dealing with tuberculosis in children (pp. 394 
and 412), and in the aged (p. 415). 

The most important form of phthisis, that of the most common 
chronic type, is the disease in which the prognosis is very difficult to 
formulate in the individual case. We may be able to prove statistic- 
ally that a certain percentage of cases recover completely; another 
percentage will survive so many years; still another percentage will 
succumb within one or two years, etc. But in the practice of medicine 
we deal with individual cases and statistics count for naught. 

In the individual case the outcome of the disease depends on so 
many complex and variable factors that it is often very difficult to 
formulate a prognosis. Indeed, we see that the most desperate case, 
slowly or suddenly, with or without any discoverable reason, takes a 
turn to the better and recovers. We see others who drag along for 
years, living, but they do not recover. Still others, in whom the 
general condition has been quite or altogether favorable, suddenly 
take a turn to the worse and the patient is carried off within a few 
weeks or months. 

For these reasons we must enter into the elements of prognosis of 
chronic phthisis in greater detail. 

Prognostic Significance of the Patient's History. — Many authors 
have stated that patients with a family history of tuberculosis are more 
likely to run an unfavorable course than those derived from non- 
phthisical stock. A consideration of the facts brought together in 
Chapter V will show that this is a fallacious view. The patient was 
undoubtedly infected during childhood. Had he suffered a massive 
infection during infancy he would have succumbed to some acute 



THE ONSET OF THE DISEASE 515 

form of tuberculosis. The fact that he survived the primary infection 
proves that it was mild; this is also the reason why he now suffers 
from chronic phthisis, and not from an acute form of the disease. 
Indeed, patients showing signs of some local tuberculous lesion at an 
earlier age usually have a slow, sluggish, form of phthisis, lasting for 
many years. Many authors have also calculated that the average 
duration of a phthisical patient with a family history of tuberculosis 
is longer than in one derived from robust stock. This is best seen in 
the acuteness of phthisis in persons who have just emigrated from 
rural districts into large cities. 

Experience teaches that the prognosis is not different in tuberculous 
adults who are derived from phthisical stock than in those ivho are not. The 
slight differences that have been discerned appear to be rather in 
favor of the former. 

Sex. — It appears that the prognosis is more favorable in women than 
in men. A man acquiring tuberculosis is apt to continue working and 
thus aggravate the prognosis while a woman, who is usually not the 
bread-winner, is more likely to abstain from overexertion, which is 
such an important element in the treatment of this disease. On the 
other hand, pregnancies, labor, and lactations are apt to aggravate 
the prognosis in women. In fact, it has been my experience that 
the prognosis of phthisis in women is better in those who are unmarried 
than in those who are married. Women are less likely to succumb 
to some of the more serious complications of phthisis, such as hemor- 
rhage, pneumothorax, etc. They also less often suffer from laryngeal 
tuberculosis. 

The Onset of the Disease. — In cases with a sudden onset the prog- 
nosis is worse than in those in whom the disease came on insidiously. 
Even the fact that the former are more apt to take strong measures 
to prevent the activity of the process does not counterbalance the 
seriousness of an acute onset, excepting when the suddenness refers 
merely to an initial pulmonary hemorrhage. An acute onset means 
severe constitutional and toxic symptoms, low powers of resistance, 
and the process in the lungs extends very quickly, so that in a short 
time quite large portions of one or both lungs are affected. 

Those beginning with hemoptysis have usually a better outlook than 
others. The reason is not clear. Perhaps the dramatic onset frightens 
the patient, and he is apt to institute proper treatment even if he feels 
well after the cessation of the bleeding, while patients with mild 
symptoms, but without hemoptysis, may continue at work till the 
disease is aggravated. But this does not explain all cases. It seems 
that hemoptysis has very often a good influence on the prognosis of 
phthisis at any stage of the disease and many patients feel much better 
after a brisk hemorrhage (see p. 220). The cases marked by an onset 
with pleurisy, dry or moist, have, as a rule, a better prognosis than 
others, as has already been stated (p. 453). It has been observed that 
patients who are only slowly regaining their health after an attack 



516 PROGNOSIS IN PULMONARY TUBERCULOSIS 

of pleurisy are pale and emaciated, are more likely to develop active 
and progressive phthisis than those who recover quickly, and soon 
regain their former health. 

Prognostic Significance of the Activity of the Disease. — We have 
seen throughout this book that the activity of the process in the lung 
has a greater influence on the ultimate outcome than the stage of the 
disease. The activity is best studied by a careful consideration of 
general or constitutional symptoms. Of these, fever is the most 
important. There is no active tuberculosis without pyrexia. The 
afebrile cases, discussed elsewhere, are rather uncommon and it is a 
fact that the prognosis is rather good, so long as fever is lacking. Each 
turn for the worse, each complication, is accompanied by a rise in the 
temperature. 

In active disease the prognosis is unfavorable in direct ratio to the 
height and duration of the fever. Every extension of the lesion manifests 
itself by increased pyrexia; persistence of pyrexia, despite rigid rest 
in bed, is pathognomonic of low resistance; the reverse type of fever, 
in which the highest point is reached in the morning instead of in the 
afternoon or evening, is of grave prognostic significance — it may be an 
indication of an invasion of both lungs by tubercles. On the other hand, 
moderate fever, less than 101° F. dropping down to normal or sub- 
normal in the morning, is rather favorable. In other words: The 
higher the morning temperature, the nearer it approaches the evening 
temperature, the worse the prognosis. Hectic fever, with normal and 
subnormal temperature in the morning, but which rises high in the 
afternoon and evening, is of grave prognostic significance. If it lasts 
for more than a month, the patient will not survive. He may last or 
even improve for a time, but he will not recover. 

A normal temperature throughout the day and night is a good sign ; 
when accompanied by a good appetite, gain in weight, diminution in 
the cough and expectoration, etc., it is an indication of healing of the 
lesion. If fever only ensues after exertion or excitement, the prognosis 
is very good indeed, provided proper treatment is instituted. It is 
for this reason that most who have new and infallible remedies for 
phthisis ask for just this sort of cases on which to try the treatment. 
The vast majority recover under any treatment, provided good nourish- 
ment and rest are part of the "cure." 

Indeed we can, in most cases, formulate our prognosis by a careful 
study of the temperature curve for a few weeks. Of course, we may on 
rare occasions err by putting implicit faith in the temperature curve, 
but the proportion of errors will be less than when we attempt to 
formulate it on other data, especially on the stage of the disease, or 
the findings on physical examination. 

For this reason, a prognosis in phthisis should not be given after a 
single examination of the patient. It is required that the temperature 
of the patient should be studied for at least two weeks before attempt- 
ing to forecast the outlook. 



PROGNOSTIC SIGNIFICANCE OF COMPLICATIONS 517 

The prognostic significance of the pulse should be considered. 
Excepting in heart disease and hyperthyroidism, no disease can be 
evaluated prognostically with the same degree of accuracy by the pulse- 
rate as chronic phthisis. Incipient cases with a pulse not above SO per 
minute have an excellent outlook. Tachycardia is an indication of 
acuteness of the process, or low resistance, or both. Patients who 
have apparently recovered but remained with a rapid pulse have a 
very poor outlook. The outlook is good in chronic cases with slow 
pulse. 

Of the other constitutional symptoms which give us prognostic 
hints, the state of the gastro-intestinal tract is of great importance. 
Patients with good appetite and who digest and assimilate their food 
well, recover, even when they have, for the time being, some fever 
every afternoon. Persistent anorexia and gastro-intestinal disturb- 
ances are of grave prognostic significance. Gain in weight in afebrile 
patients with good appetite is a good sign. But occasionally we meet 
a patient who holds his own, or even gains, despite the fever. In such 
cases the thermometer should be our guide, and not the scale. 

Hemoptysis has no influence on the course and prognosis of the disease 
in the vast majority of cases. The initial hemoptyses are rather salutary, 
as was stated above. Xo patient has succumbed to a really initial 
hemoptysis. Ninety-eight per cent, of cases of advanced disease 
recover from hemorrhages. But in cavitary cases, which may or may 
not be doing well, a brisk hemoptysis may unexpectedly kill the 
patient. In the average case, if the hemoptysis is not accompanied 
by fever, or the fever lasts only a few days after the cessation of active 
bleeding, the prognosis is good. But if pyrexia continues it may point 
to acute pneumonic phthisis, or to tuberculous bronchopneumonia 
which is almost invariably fatal. In these cases the hemoptysis is 
indirectly responsible for the fatal issue. 

The blood-pressure of the patient may give us some valuable prog- 
nostic hints. Those with hypertension have a better outlook for 
recovery than those showing hypotension. Low blood-pressure is 
characteristic of feeble heart action due to the tuberculous toxemia 
acting unfavorably on the cardiac muscle. So long as the blood- 
pressure remains low, the prognosis is serious. With the improvement 
in the general condition of the patient there is almost invariably 
noted an increase in the blood-pressure. When there appears during 
the course of phthisis an abnormally high blood-pressure, an exami- 
nation of the urine may disclose the presence of albumin and casts. In 
fibroid phthisis, and in some cases of phthisis in gouty and rheumatic 
individuals, the blood-pressure is normal or above normal and the 
prognosis is good. 

Prognostic Significance of Complications. — The presence of com- 
plications, tuberculous and others, modifies the prognosis perceptibly. 
Thus, laryngeal and intestinal tuberculosis aggravate the prognosis. 
Though many recoveries are seen in patients with these affections, 



518 PROGNOSIS IN PULMONARY TUBERCULOSIS 

yet in the individual case we must not give a favorable prognosis in 
those who show positive proof of laryngeal or intestinal complication. 
With advanced laryngeal disease, manifesting itself in aphonia, dys- 
phagia, etc., a fatal issue is to be expected. The same is true of diarrhea 
which lasts more than a month. We occasionally, however, see patients 
with profuse diarrhea lasting for several months. But they never 
recover. Blood in the stools is another unfavorable sign. Ischiorectal 
abscess is itself an indication of intestinal tuberculous ulceration and 
is of unfavorable prognostic significance. 

Pleurisy is not invariably an unfavorable complication. The dry 
form occurs in nearly all chronic cases and has a rather salutary 
influence on the pulmonary lesion ; it is also a good preventive of spon- 
taneous pneumothorax. Pleural effusions are serious, though in many 
cases they have a good influence on the basic disease. We have 
already shown that they occasionally promote the healing of the lesion 
in the lung by compression . But in bilateral lesions the side with a 
free pleura is likely to suffer from an extension of the tuberculous 
process and the outlook is gloomy. 

Empyema is a very bad complication . No recovery is to be expected . 
The patient may last for months, but he will not recover. On exceed- 
ingly rare occasions the pus breaks through a bronchus and is expec- 
torated. But even here the ultimate outlook is bad, because of the 
amyloid degeneration of the viscera and the general malnutrition 
caused by the prolonged suppuration . 

Spontaneous pneumothorax is fatal in 95 per cent, of cases within 
one month of its occurrence. The exceptions have already been 
mentioned. 

Tuberculosis of the kidney is of unfavorable import. 

Of non-tuberculous complications we may mention influenza. This 
disease is more often diagnosed in tuberculous patients than facts 
would warrant. An increase in the cough, pyrexia, etc., due to an 
exacerbation of the tuberculous process, is apt to be attributed to 
influenza by patients and physicians. Lobar pneumonia occasion- 
ally occurs in phthisical patients. In the cases observed by the author 
the outcome depended on the condition of the tuberculous lung. Those 
with slight quiescent lesions may pass through an attack of pneu- 
monia, recover, and the phthisis should pursue its course as if no such 
complication had occurred. But in patients with extensive tubercu- 
lous lesions, reduced in vitality, the pneumonia is the last straw and 
the patient is carried off within a week. 

We often meet other non-tuberculous diseases in patients suffering 
from phthisis. Such as necessitate an operation with the administra- 
tion of a general anesthetic are dangerous, and it has been my rule to 
urge local anesthesia, whenever feasible, in operations on tuberculous 
subjects. But when a general anesthetic is imperative, the outlook 
is not so grave as popularly supposed. Many tuberculous patients 
under my care have been operated upon and held under the influence 



SIGNS FOUND ON PHYSICAL EXAMINATION 519 

of ether or chloroform for more than an hour, yet they did well after 
recovering from the operation. In most cases the lesion in the lung 
keeps on pursuing its course as if no surgical interference had been 
instituted. CD. Parfitt reports that 5 per cent, of his sanatorium 
patients during seven years had to undergo major surgical operations 
with general anesthesia. Despite the surgical shock and anesthesia, the 
pulmonary condition was not aggravated in any case. Similar experi- 
ences are reported by H. G. Wetherill of Denver, and H. M. Kinghorn. 
It seems that the entire problem rotates around the activity of the 
pulmonary lesion. An anesthetic administered to a patient with 
extensive lesions in the lungs, running high fever, having a rapid pulse, 
and other symptoms of tuberculous toxemia, will but accelerate the 
inevitable, or aggravate the slight chances of improvement. But when 
the lesion is quiescent, the temperature and pulse around normal, and 
the general condition fair or good, the patient will stand the shock of a 
major operation with general anesthesia. 

Pregnancy is a grave complication of phthisis, and in incipient cases 
it is advisable to induce abortion whenever it occurs. For this reason 
it is urgent that married phthisical women should be instructed in the 
methods of prevention of conception. During pregnancy the patient 
may feel well, even better than before conception has taken place. But 
after childbirth there is often a reactivation of the tuberculous process 
and an acute course of the disease is likely to ensue. 

Prognostic Significance of Signs found on Physical Examination.— 
We have already mentioned the fallacy of formulating the prognosis of 
phthisis solely on the findings by physical examination. There are 
cases showing physical signs indicating that we are dealing with 
incipient, or first-stage, cases of the American or Turban's classification, 
yet the prognosis is very unfavorable. Indeed the most unfavorable 
prognosis should be given in cases showing marked constitutional symp- 
toms which are out of proportion to the findings on physical examination. 

It may be stated that generally the extent of pulmonary involve- 
ment is of more importance than the stage to which the lesion has 
advanced. Cavitation in one lobe is of less danger than infiltration 
of two or three lobes. J. Edward Squire gives the following table 
embracing 2720 cases of phthisis showing the relation of improvement 
to the number of lobes involved : 







Much improved. 


Improved. 


Total impro\ 


eel 


affected. 


Cases. 


Per cent. 


Per cent. 


Per cent. 




1 . . 


877 


58.38 


28.62 


87 


00 




2 . . 


. 1015 


37.83 


34.67 


72 


50 




3 . . 


. 515 


22.52 


35.53 


58 


03 




4 . . 


. 277 


15.16 


29.24 


44 


40 





The fear and apprehension entertained by both the profession and 
the patient for "holes in the lung" are based on misconceptions of the 
pathology of phthisis. The fact is that the most dangerous pases of 
progressive phthisis are fatal before cavities are formed. This is the 



520 PROGNOSIS IN PULMONARY TUBERCULOSIS 

case with miliary tuberculosis and, to a certain extent, with acute 
pneumonic phthisis. If a tuberculous lesion in the lung does not cica- 
trize quickly, the best that can happen to the patient is that a cavity 
should form. A pulmonary cavity is proof that the organism is in 
possession of strong powers of resistance, in fact, of immunity; otherwise 
the lesion would spread. The difference between active phthisis with 
cavity formation and without such occurrence is analogous to that 
between general septicemia and abscess. In the latter case the disease 
is localized and circumscribed and, when drained, the danger is not very 
great. A cavity has, in fact, been defined as a tuberculous abscess 
which is drained through a fistulous opening into a bronchus. 

This is a fact which is not appreciated at present to the extent it 
deserves, though nearly one hundred years ago that keen clinical 
observer Laennec already spoke of it. He said: " Pretty often, at the 
period when the complete evacuation of a tuberculous cavity is indi- 
cated by the stethoscopic signs, the patient experiences a marked 
improvement in his symptoms: the expectoration and fever decrease, 
and, if the improvement only lasts a little while, even the wasting of 
the body is sometimes diminished. This false convalescence is usually 
only of a few days' or weeks' duration; but it may extend to some 
months, and may even seem to be complete. . . It may even, in 
some rare instances, terminate in a perfect and permanent restoration 
of health." 

It may be stated that the dangers of tuberculous cavities vary inversely 
with the time it takes for their formation. The sooner they are produced, 
the worse the prognosis; the slower they develop, the better the ulti- 
mate outlook. In very acute forms of phthisis cavitation is very rare. 
The prognosis is gloomy with or without localized destruction of pul- 
monary tissue. In adults such cases are comparatively rare, but in 
infants rapid cavity formation is seen at times, and the termination is 
almost invariably fatal. In subacute forms of phthisis, in wliich exca- 
vations are apt to form very rapidly, the prognosis is unfavorable, 
unless the cavity is rather small. In the latter case the disease may 
be attenuated, and subsequently pursue a chronic course with the 
sequestration and expulsion of the affected area. Excavation is then 
the first step toward the diminution of the acuteness of the process in 
the lung. The general symptoms may be ameliorated, as after the 
evacuation of an abscess. 

In chronic phthisis excavations, even when extensive, are compatible 
with a long and efficient life. These cavities are surrounded by more or 
less dense fibrous capsules which limit their extension, and are drained 
through fistulous tracts communicating with bronchi. So long as the 
secretions are eliminated by expectoration, the patient may feel quite 
comfortable for years. The cavities may even heal, as was already 
shown (see p. 151). When small, they may be obliterated by granula- 
tions or by calcification of their contents. Larger excavations may 
shrink or, even when remaining of large dimensions, they may become 



SIGNS FOUND ON PHYSICAL EXAMINATION 521 

altogether benign after the necrotic tissue has been expelled. They 
are, however, a constant source of danger of metastatic auto-infection 
or copious hemorrhages. 

In my experience patients with right-sided lesions of this type are more 
likely to recover than those with left-sided lesions. In the former the 
constitutional symptoms, especially dyspnea, tachycardia, etc., may 
improve or disappear after the formation of a chronic cavity and the 
disappearance of the pyrexia. Even dextrocardia may be well borne. 
But in left-sided lesions the heart is pulled over to the left and upward, 
and the patient remains w T ith tachycardia and is distressingly short- 
winded. Pneumothorax is more likely to occur in the left pleural 
cavity. 

The rational explanation for the mildness of right-sided lesions as 
compared with those in the left side is this: The left lung is smaller 
than the right and has but two lobes. The division of the lung into lobes 
retards the spread of tuberculous process — the interlobar fissures, lined 
with double layers of serous membrane, act as barriers. In the right 
lung with three lobes there are two fissures, while there is only one in 
the left lung, and when this is passed, the entire lung is invaded. In 
addition, in extensive left-sided lesions, the diaphragm is drawn upward 
and with it the stomach, while the heart is pulled over to the left 
and upward ; in some cases the apex beat may be found in the third 
interspace in the axillary line. The result is almost invariably dis- 
turbances in the circulation due to mechanical causes; the dyspnea 
is severe; more so than in dextrocardia found in right-sided lesions. 
Gastric symptoms, due to displacement of the stomach, are also very 
frequent in extensive lesions of the left lung. While I have seen many 
cases with cavities in the right lung and dextrocardia recover, I have 
seen but few with large excavations in the left lung do well. They may 
last for many years, but they are always unable to do anything because 
of severe dyspnea, cyanosis, etc. 

In. chronic cases in which the formation of a cavity is slow, the 
prognosis is rather good. In fact, cavity formation, as we have already 
shown, is a sign of immunity. Those with little or no resistance 
succumb before there is an opportunity for cavity formation. 

These cavities are surrounded by dense fibrous capsules which limit 
their progress or extension, and they may be harmless for long periods 
of years. Communicating with bronchi which permit the expulsion 
of the morbid secretions forming on the ulcerated wall, they often 
pursue an apyretic course. Some even have smooth and glittering 
walls without any lymph spaces, and the toxic products within them 
cannot be absorbed. We meet with cases in which even the tubercle 
bacilli disappear from the sputum and the prognosis is the same as 
in bronchiectasis. 

There are many of this class of patients who, despite having more or 
less extensive excavations, live for many years without pronounced 
inconvenience; in fact, some consider themselves fairly healthy and 



522 PROGNOSIS IN PULMONARY TUBERCULOSIS 

attend to their callings, or even to manual labor. Their main trouble 
consists in a proclivity to "catch cold," and only on such occasions 
do they call on their physicians for relief. 

Generally speaking, tuberculous cavities are indications of chronicity 
of the tuberculous process in the lung, showing that the resisting forces 
are active and as such are of better prognostic augury than many active 
incipient cases. 

Patients are to be told that the "holes" in their lungs per se are 
not so dangerous as they believe. That fever, anorexia, etc., are 
more dangerous. They may live and can be active with cavities for 
many years. 

Special Tests. — Various attempts have been made to find tests of 
the severity of phthisis by examination of the blood, urine, etc. We 
have already seen that Arneth's blood picture is not so reliable as some 
would lead us to believe (see p. 244). Ehrlich's diazo-reaction was 
at one time considered reliable in indicating the severity of phthisis. 
But it appears that it is positive in cases which are otherwise indicating 
their progressive tendencies. In incipient cases it is, as a rule, negative, 
but I have met with cases in which it was positive, yet the case went 
on to uneventful recovery. It appears that at present very few place 
great reliance on this test. 

Moritz Weisz 1 found that urochromogen is the principal substance 
which causes the diazo-reaction, and suggested that his test is superior 
to the latter. I used Weisz 's urochromogen test and found it superior 
to the diazo-reaction in indicating the prognosis of active phthisis. It 
is thus performed: Into each of two small test-tubes are put 8 c.c. of 
urine and 2 c.c. of distilled water are added; now, to one tube which is 
to be tested for urochromogen, 3 drops of 1 to 1000 solution of potas- 
sium permanganate are added, the tube is shaken thoroughly and com- 
pared with the control tube. The appearance of the faintest yellow 
color shows the presence of urochromogen and is easily detected by 
comparing with the control tube, to which no potassium permanganate 
is added. The test is read positive, however, only when the solution 
stays clear. 

In this country Heflebower, 2 and J. Metzger and S. H. Watson 3 
have reported that this test is a reliable guide in estimating the activ- 
ity of the tuberculous process and gives indication as to prognosis. I 
find that it is positive during acute exacerbations of the disease and is 
usually negative in incipient, or even in quiescent, cases. In acute 
progressive cases it is found positive, and it becomes more and more 
intense with the extension of the disease. It is negative in most 
favorable cases. 

The complement-fixation test, which has of late been used in the 
diagnosis of tuberculosis with doubtful results (sea p. 347), has been 

1 Miinchen. med. Wchnschr., 1911, lviii, 1348. 

2 Am. Jour. Med. Sc, 1912, cxliii, 221. 

3 Jour. Am. Med. Assn., 1914, lxii, 1886. 



ECONOMIC CONDITIONS OF PATIENTS AND PROGNOSIS 523 

found by some authors to have some prognostic value. Debains 
and Jupille 1 report that in active incipient and hopeful cases of phthisis 
the reaction is usually positive, while in advanced cases with pro- 
nounced emaciation the reaction is often feeble or altogether negative. 
They try to explain these phenomena on the assumption that in pro- 
gressive and advanced phthisis the antibodies in the serum have already 
been bound or neutralized by the substances produced by the tubercle 
bacilli. They also found that in experimental tuberculosis in rabbits 
complement-fixation activity goes hand-in-hand with the resistance of 
the animal. On the other hand, in tuberculous pleurisy with effusion 
negative reactions were mostly found, and this form of the disease 
cannot be considered as of especially unfavorable prognosis. In fact, 
we have shown that the outlook in pleurisy is rather bright. Most of 
the work along these lines was done by Besredka, 2 who reported that 
the reaction is uniformly positive in early cases of phthisis; in moder- 
ately advanced cases it is positive in the majority. With the advance 
of the disease the reaction becomes feeble, and finally in the terminal 
stages of phthisis it becomes negative. With Manoukhine he regards 
a negative reaction in advanced phthisis as a sign of approaching death. 

From the results obtained by H. R. Miller in my wards at the 
Montefiore Hospital, the complement-fixation test showed no indi- 
cations that it may be utilized for prognostic purposes. It has been 
found positive in active, as well as in quiescent or healed cases, and as 
often negative in cases in which the contrary might have been expected. 

Influence of Economic Conditions of the Patients on the Prognosis. — 
The occurrence of phthisis is in itself an indication of poverty. To 
be sure, we meet with numerous rich consumptives, but economic 
prosperity is not always an indication of rational life, proper food, 
regular hours, avoidance of physical and mental overexertion, etc. 
But in a given case of phthisis the prognosis is often influenced more 
by the social and economic condition of the patient than by any other 
single factor. After all, phthisis is the most expensive of diseases because 
it disables the patient for a long period of time and requires costly 
treatment, including nourishment, a favorable home, etc. 

The patients who can afford to bear the expense are more likely to 
recover than those who cannot. The artisan often has a family depend- 
ing on him for support, and he is likely to keep at work while sick, till 
the disease has progressed to a stage where he can do no more, and drops 
from sheer exhaustion. It is in these cases that the institutions, as well 
as the social service of modern enlightened communities, do consider- 
able to improve the prognosis of phthisis. But it must always be borne 
in mind that these agencies can do much better than merely give advice 
about the dangers of living with tuberculous persons, and distribute 
scare head literature and sputum cups. If they do only this, the prog- 
nosis is often aggravated because the patient is, at times, treated like 

1 Compt. rend. Soc. de biol., 1914, lxxvi, 199. 

2 Ann. de l'lnst. Pasteur, 1914, xxviii, 569; Compt rend. Soc. de biol., 1914, lxxxvi, 197, 



524 PROGNOSIS IN PULMONARY TUBERCULOSIS 

a pariah by his relatives and friends who are frightened by the numer- 
ous "visitors," the social workers, nurses, physicians, and others. I 
have seen families broken up in this manner; families in which there 
were no infants, and there was no reason to fear dissemination of the 
disease. But what is of most importance, the patient, deprived of the 
comfort of a good home, becomes despondent and the lesion progresses 
more quickly than it would otherwise. 

Antagonistic Diseases. — We have already seen that individuals 
suffering from mitral stenosis are less likely to develop phthisis, despite 
the fact that they are just as much exposed to infection as others 
(p. 102) . In fact, it appears that a hypertrophied heart, due to any 
cause, is more or less of a protection against phthisis; if the latter 
does occur, it runs a milder course and tends to heal. 

Phthisis is characterized by arterial hypotension, and this may be 
the reason why it is so rare in patients with arteriosclerosis, and 
when it does occur, it runs a benign course. In fact, it is rare to find 
arteriosclerosis in phthisical patients with albuminuria, casts, etc., 
indicating that they have chronic nephritis. Similarly, persons 
suffering from interstitial or parenchymatous nephritis of a chronic 
type become phthisical only rarely. In the aged — arteriosclerotics — 
phthisis runs an exceedingly chronic course, as we have already shown. 

French authors have described an antagonism between the arth- 
ritic and the phthisical diatheses. M. Raynaud noted that in gouty 
individuals phthisis, when it does occur, has a better outlook than in 
the average patient. The lesion is usually limited to one apex and 
runs a latent course. A marked tendency to fibrosis is seen in and 
around the lung lesion. Well-nourished consumptives — the "fat 
consumptives" already mentioned — are mainly found among arthritic 
subjects or persons of arthritic stock, and also among those who were 
scrofulous during early childhood, as has been shown by Pidoux, 1 
Sokolowski, 2 and others. Even when they suffer from hemoptysis, 
which is not rare, they recuperate rather quickly, and are none the 
worse for their experience. Lemoine 3 maintains that tuberculous 
arthritics supply the main contingent of the curable cases of phthisis, 
and among them are those who, despite tuberculosis, reach an advanced 
age. The nutrition of the patient is also affected to a lesser degree in 
scrofulous individuals when they become phthisical, even when the 
process is extensive. He believes that the tendency to evanescent 
congestive conditions promotes sclerosis of the lesion. But we now 
have a better explanation. Scrofulous individuals are endowed with 
a high degree of immunity against tuberculosis. 

English writers, who have seen many gouty patients, confirm 
these observations. J. E. Pollock believed that "gout, like rheu- 
matism, when the specific attack of the disease is developed in a 

1 fitudes generates et pratiques sur la phtisie, Paris, 1873. 

2 Deutsch. Arch. f. klin. Med., xlvii, 558. 

3 Semaine Medicale, 1900, xx, 103. 



PROGNOSIS IN ARRESTED DISEASE 525 

case of tubercle, retards the latter." Sir Dyce Duckworth supposes 
gout, or the gouty diathesis, is antagonistic to phthisis. F. Parkes 
Weber 1 suggests that the resistance of gouty persons toward tubercu- 
losis is probably partly due to the meat food (butcher's meat, eggs, and 
all animal protein foods) which most persons with acquired goutiness 
have been accustomed to indulge in freely during most of their lives. 
He suggested that there might be some substance circulating in the 
blood in gouty persons in minute quantities, yet sufficient to have 
an antagonistic action toward the growth of tubercle and that perhaps 
this was likewise the case in persons taking an unusual amount of food, 
which might partly account for the good results following the extra 
feeding of phthisical patients, when duly assisted by hygienic sur- 
roundings. "Great meat eaters, if not alcoholic, rarely, even in the 
most unhygienic surroundings, become phthisical." Sir Andrew Clark, 2 
Herman Weber, 3 and others, noted the antagonism between gout 
and phthisis. Weber even urges the acceptance as insurance risks 
of persons affected with fibroid phthisis, also such as have gout and 
tuberculosis, because they have great resistance against the ravages of 
phthisis. Bandelier and Ropke found that in individuals with a dis- 
turbed purin metabolism, phthisis is always chronic or latent and shows 
strong tendencies to fibrosis. Raw 4 regards the gouty diathesis as 
antagonistic to tuberculosis and he found that the blood of a gouty 
person is not a suitable medium in which the bacilli will flourish. 

From personal experience the writer is inclined to agree with Mayer 5 
that the antagonism applies only to constitutional gout, while gout 
resulting from plumbism rather favors the development of phthisis. 
I have, in fact, seen many cases of subacute phthisis running a rapid 
course in house painters who have for years suffered from lead poison- 
ing and atypical gout. Most of them, however, suffer from fibroid 
phthisis. 

It also appears that syphilis, while not antagonistic to the develop- 
ment of phthisis, yet influences the latter disease so that it runs a 
mild course, showing strong tendencies to fibrosis. Fibroid phthisis 
is very often seen in old luetics, and antisyphilitic treatment has a 
good influence on both diseases. On the other hand, when a consump- 
tive acquires syphilis both diseases are apt to run a rapid or even a 
malignant course. 

It is curious that many pathologists consider cancer antagonistic to 
tuberculosis. Rokitansky found that organs liable to tuberculous 
degeneration, such as the lungs, are only rarely attacked by cancer; 
the reverse is also true — the ovaries, stomach, esophagus, liver, etc., 
which are liable to cancerous invasion, are only rarely tuberculous. 
Lebert, Williams, Lubarsch, and others, confirmed these allegations. 

1 Lancet, 1904, i, 924. 

2 Tr. Med. Soc, London, 1889, xiii, 9. 

3 Medical Examiner, 1898, p. 122. 

4 Tuberkulosis, 1911, x, 169. 

sZtschr. f. Tuberkulose, 1914, xxiii, 243. 



526 PROGNOSIS IN PULMONARY TUBERCULOSIS 

Dabney even suggested tuberculin in the treatment of certain forms 
of cancer. But recent investigations of Moak, McCaskey, and espe- 
cially A. C. Broders, 1 seem to indicate that tuberculosis is quite often 
found associated with malignant neoplasms. "It would seem," says 
Broders, "that the reason pathologists are not finding tuberculosis 
more frequently at necropsies in persons who have died with malignant 
neoplasia is that the pathologists are satisfied to find the malignant 
neoplastic condition and therefore fail to make a thorough search for 
tuberculosis." 

Prognosis in Arrested Disease. — We have seen that only lesions 
of abortive tuberculosis are completely healed by cicatrization and 
calcification. But this form of the disease is not recognized, as a rule, 
during its activity and the prognosis is good at all events. It is 
different with chronic phthisis which has lasted for some time and 
finally there is an abatement in the constitutional symptoms and the 
patient is considered cured. 

Cure by restitutio ad integrum is out of the question in these cases. 
The cicatrized and calcified foci usually contain virulent tubercle 
bacilli which may at any time become active again, flaring up the lesion 
or causing metastatic auto-infection. Experience has taught that in 
the vast majority of cases these patients attain but "quiescence," and 
the term "arrested disease," which has recently been substituted for 
the term "cured," w T hich was formerly in vogue, is proper. The 
patient is justified in asking for an opinion whether this arrested con- 
dition is likely to be lasting, or whether he will sooner or later suffer 
from a recrudescence of the symptoms of phthisis, a relapse which is, 
in fact, an acute or subacute exacerbation. In other words, is the 
arrest of the disease an indication of a more or less permanent freedom 
from tuberculous sickness or is it merely a long remission in the 
progress of the disease? 

These problems can be solved, in many cases, by a consideration of 
the physical signs found in the chest but with greater certainty when 
the constitutional symptoms are considered. 

Physical exploration of the chest discloses usually signs of cicatriza- 
tion of the involved lung tissue, pleural adhesions, evidences of fibro- 
sis, w 7 hile the rest of the lung may show indications of emphysema. 
Adventitious sounds are usually, though not invariably, absent; the 
case is "dry." Exquisite amphoric breath sounds may be heard over 
the site of cavities, combined with amphoric w T hispered voice, but no 
rales. In others, the site of the lesion is only discovered by the dulness 
on percussion, and feeble breath sounds and sibilations are found over 
a circumscribed area of the chest, usually the upper part of one side. 
In many there are found signs of displacement of the mediastinum. 
But we have already emphasized the fact that the physical signs 
elicited on the chest are of but little value prognostically. The writer 

1 Jour. Amer. Med. Assn., 1919, lxxii, 390. 



PROGNOSIS IN ARRESTED DISEASE 527 

is under the impression that a patient showing a well-defined line of 
demarcation between the normal lung and the affected part has a better 
prognosis than one showing a gradual change from normal to pathological 
lung tissue. But to this there are many exceptions. 

The problems, "Will the quiescence last?" and "Is the patient in 
danger of a relapse of the disease?" can best be answered by a careful 
consideration of the constitutional symptoms. In general terms it 
may be stated that the patient is in danger of two accidents: (1) 
pulmonary hemorrhage; and (2) reactivation of the disease. 

Pulmonary hemorrhage cannot be foreseen in these cases, nor can 
it be prevented. It may occur when the patient is in excellent condi- 
tion. When not copious, it merely frightens him, but even brisk and 
copious hemorrhages are well borne by 98 per cent, of patients; in 
fact, they feel better in many cases after recovery from the bleeding, 
and quickly recuperate. Some have one such large hemorrhage a few 
years after recovery from the phthisis and feel well for many years 
thereafter, or even for the rest of their natural lives. But in about 2 per 
cent, of these bleeders the hemorrhages prove fatal. As was already 
stated, these hemorrhages cannot be foreseen nor prevented. Those 
suffering from "recurrent hemoptysis" hardly ever perish because 
of the bleeding. The danger is a brisk hemorrhage occurring suddenly 
in one who may not have bled before. 

An exception is, however, to be made in the case of streaky sputum. 
In many patients with well-healed lesions in the lungs, minute hemor- 
rhages occur, especially after slight exertion or acute non-specific 
infections of the upper respiratory tract, etc. So long as there is no 
fever, severe cough, etc., this is to be considered as capillary hemor- 
rhage due to ruptures of minute bloodvessels in the sclerosed pul- 
monary tissue. These slight attacks of hemoptysis are a good sign of 
healing, and should not alarm the patient. It is different with copious 
attacks of hemoptysis of which we spoke above. They are liable to 
threaten life on rare occasions. 

Healing of the tuberculous process in the lung frequently leaves the 
patient with certain annoying symptoms for an indefinite time. Many 
have pains in the chest, which may be aggravated during meteoro- 
logical changes. This is particularly observed in patients who have 
pleural adhesions. In some the pain is paroxysmal, coming on without 
any known provocative cause, lasting for several days, and disappear- 
ing. No improvement can be attained by therapeutic intervention. 
But the patient may be assured that these pains are no indication of a 
recurrence of the tuberculous process, so long as there is no elevation 
in the temperature or an acceleration in the pulse rate. 

The constitutional symptoms are better guides in prognosis as to 
the chances of a lasting quiescent period. Most of these patients 
with arrested phthisis remain emaciated, anemic, with wasted muscles, 
often presenting a cadaverous appearance. Despite this, many of 
them are very active at their avocations and in fact they display energy 



528 PROGNOSIS IN PULMONARY TUBERCULOSIS 

and perseverance which is surprising when considered in connection 
with their physical decrepitude. Some are rather well nourished 
despite the fact that physical exploration shows a lesion of various 
degrees of activity, from cicatrization to excavation. In my expe- 
rience, patients apparently well nourished, with quiescent or arrested 
lesions of this class are not as a rule doing as well as those of the lean 
type, despite their well-nourished bodies. We should not allow our- 
selves to be deceived in attempting a forecast by the amount of fat the 
patient has, by the fresh and browned skin which is often merely a 
superficial mask of improvement, while the interior of the organism is 
vitally undermined. 

The prognosis in these two classes of patients can only be determined 
with some degree of certainty by an analysis of the following condi- 
tions: If the improvement has been attained through careful treatment in 
a favorable environment, the test is whether the patient remains in good 
condition for some time after returning to his old environment without 
suffering a relapse of the constitutional symptoms. The test, in other 
words, is duration; improvement counts if it lasts without special 
treatment. 

So long as there is but little cough, or none at all, no fever, no tachy- 
cardia, dyspnea, chills, sweats, etc., the prognosis is good, no matter 
what physical exploration discloses. Continuous freedom from these 
symptoms for several months is an indication of arrest, even if tubercle 
bacilli are found in the sputum, while in those in whom arrest has just 
been attained, the prognosis is uncertain until time has shown that 
there is no tendency to recrudescence. The prognosis is even better 
in those who, despite resumption of their previous occupation or tak- 
ing up a new one, and living a rational, though not an exceptionally 
careful life, still keep in good condition. On the other hand, in those 
who purchased quiescence or arrest of the disease by special treatment, 
rest, and extreme care, the prognosis is less favorable, unless resumption 
of ordinary activities of life proves that recrudescence does not occur. 

In short, the prognosis of quiescent and arrested disease can only 
be made by a careful observation, for several months, noting the effects 
of resumption of activities of life on the condition of the patient. 



CHAPTER XXXI. 
THE INDICATIONS FOR TREATMENT OF PHTHISIS. 

The indications for treatment in pulmonary tuberculosis appear at 
first sight to be simple and clearly defined. On the principle that the 
first thing to do is to remove the cause, it would seem that there are 
but two procedures to follow: To destroy the bacilli which have 
settled within the body; or to increase the resisting powers of the 
patient, and thus render the soil unsuitable for the growth of the 
invading virus. But in this case, the ideal, like other ideals, cannot 
be achieved in the average case, and the aim at curing the patient by 
the first of these procedures is not feasible at the present state of our 
knowledge. 

We have no chemical remedy which will destroy the bacilli harbored 
within the body without simultaneously killing the patient. We have 
no drug which will render the tubercle bacilli harmless in the body, 
as quinin destroys the Plasmodium malaria?, or salvarsan and mercury 
destroy the spirocheta in syphilis, leaving the patient in good shape. 
Even the so-called specific treatment — the various tuberculins, sera, 
and vaccins — which have been lauded for their alleged curative powers 
when properly administered, are not stated to have any known bacteri- 
cidal action, nor are they known to hinder the proliferation of the 
bacilli within the body, or to immunize the tissues against the poisons 
engendered by these microorganisms through the production of anti- 
bodies, as is the case with antitoxins. Attempts at active immuniza- 
tions have not met with notable success in tuberculosis. 

The etiology of tuberculosis, however, teaches a lesson in rational 
therapeutics. The tubercle bacilli do not grow with equal facility in 
every individual; if they did, the number of human beings who suc- 
cumb to this disease would be equivalent to the number that give posi- 
tive reactions to tuberculin, indicating that they have been infected 
with tubercle bacilli — over 90 per cent, of the adult population in 
large urban centers. We have seen that the bacilli can proliferate and 
produce their noxious effects only in persons who offer a favorable 
soil for their existence. 

In what this favorable soil consists, we are not altogether clear. 
In the chapter on Predisposition we discussed it in detail, and it was 
evident that everything which undermines the general health of a 
person and reduces his vitality may prepare a favorable soil for the 
growth of tubercle bacilli within the body, and thus produce phthisis. 
As a corollary we may argue that anything which will stimulate the 
vital defensive forces, which are more or less inherent in every indi- 
34 



530 THE INDICATIONS FOR TREATMENT OF PHTHISIS 

vidual, or which will improve the nutrition of the body may hinder 
the proliferation of the bacilli, and with the improvement in the gen- 
eral physical condition of the patient the local lesion may cicatrize, 
or the dissemination of the bacilli by metastasis may be prevented. 

This is what modern phthisiotherapy is aiming at in handling each 
individual case of the disease. As has been pointed out by G. Schroder, 1 
modern therapeutic tendencies, which are based on the achievements 
of immuniology, have not changed our methods of treatment of tuber- 
culosis, especially phthisis. It is today, as it was hitherto, based on 
the general principles of therapeutics, because phthisis as a disease 
cannot be considered an infectious disease sui generis. It can only 
originate in individuals with a certain constitutional susceptibility, 
which may be inherited or acquired. 

Air, Food, and Rest. — The traditional therapeutic triad — air, food, 
rest — has withstood the test of time, and is at present called into 
service more often than ever before in the treatment of phthisis. 
Indeed, like many other excellent therapeutic agents which have be- 
come standard, it is very often abused. Many patients know of it and 
quite often tell their doctor that they are aware of the fact that medi- 
cine is helpless and that air, food, and rest are all that they need. 
Curious to say, some physicians do not protest. 

But this is all wrong. The medical man of today has many more 
resources in his attempts at curing phthisis and should not rely on 
the above-mentioned triad exclusively. Indeed, a physician who 
advises a patient to lead an open-air life in some region famous for its 
beneficial effects on this disease, and urges him to consume more and 
better nourishment than he has been in the habit of taking, and to 
stop all life activities, fulfills but part of his duty to his patient. There 
are many more therapeutic resources which hasten recovery, relieve 
the most annoying and painful symptoms of the disease, and go a 
long way toward prevention of complications, which cannot be met 
by the above-mentioned indications. 

Effects of Polymorphism of the Disease on Therapeutic Indications. 
— Since the etiological unity of tuberculosis has been proved by the 
discovery of the tubercle bacillus, the profession has tacitly accepted 
that unity of origin invariably implies unity of effect, and the treat- 
ment of the disease was also unified. But this is an error. We have 
seen that the tubercle bacilli produce different lesions in different 
individuals, as regards the anatomical changes in the lung, the clinical 
phenomena, and the course and curability of the disease. Indeed, 
there are hardly two cases of phthisis which appear exactly alike on 
the autopsy table, and all the groupings into caseous, fibroid, cavitary, 
pneumonic, etc., are inadequate. This is especially true of the clinical 
manifestations of the disease; its polymorphism is noteworthy and 
important. To be sure, this is also true of other diseases, notably 

1 Handbuch der Tuberkulose, 1914, ii, 1. 



CRITERIA OF EFFICACY OF TREATMENT 531 

syphilis, yet the specific remedies in the latter answer most of the 
indications. So long as we are not in possession of a specific remedy 
for tuberculosis, it will have to be treated symptomatically. 

Under the circumstances, to be effective, treatment must be applied 
in accordance with the clinical manifestations encountered, and to a 
certain extent with the clinical form of the disease. We have seen that 
each form pursues a course more or less different from all other forms. 
It would therefore be wrong to treat a patient with abortive tubercu- 
losis in the same manner, and for the same length of time, as one with 
chronic progressive phthisis. Fibroid phthisis demands different treat- 
ment from chronic caseous phthisis; febrile cases cannot be treated 
like those which run an afebrile course. The various complications 
of the disease, like intestinal, laryngeal, and renal tuberculosis, demand 
special care which the general indications do not satisfy. Preexisting- 
disease, like syphilis, diabetes, cardiovascular and renal derange- 
ments, etc., alter the course of treatment appreciably. There are also 
differences in our methods of treatment when we care for a tuberculous 
child, as compared with those applied in adults; but in senile phthisis 
the indications are not the same as those in adolescents. The indica- 
tions are even different in cases of young, single women, as compared 
with married or pregnant women, and during the menopause tuber- 
culosis often demands special treatment. 

It is thus obvious that a method of treatment which will suit all 
cases cannot be formulated. What may be efficacious in one may not 
be feasible in another, or even harmful in a third. The treatment of 
phthisis must be individualized to suit the case; it must be elastic and 
adaptable to the polymorphous nature of the disease and to the various 
accidents and complications occurring during its course. 

Criteria of Efficacy of Treatment. — In judging the value of any 
method of treatment, we must bear in mind some points which are 
usually neglected while speaking, of this subject. The fact must not 
escape vs that the vast majority of cases of tuberculosis manifest a 
strong tendency to recover under any method of treatment, or even 
spontaneously. Impressed by the malignancy of the disease in many 
cases, we are apt to forget the large number of spontaneous recoveries, 
and when we meet with good results, we are apt to attribute them to 
the method of treatment pursued, forgetting that a large proportion 
of patients would have recovered without the treatment. 

Discussing the clinical features of abortive tuberculosis, we have 
shown that this form of phthisis is very common and may not be 
recognized. When reading about a large proportion of recoveries in a 
sanatorium which admits only "incipient" cases, or of a drug which is 
alleged to cure at this stage a certain proportion of cases, etc., we must 
recall that among these "early" cases, there are a large number with 
a strong tendency to recovery under all circumstances. To be of real 
value, a method of treatment must be effective in producing more 
recoveries than would be ordinarily anticipated. 



532 THE INDICATIONS FOR TREATMENT OF PHTHISIS 

Even in the forms of chronic phthisis which usually last for many 
months or years before terminating in recovery or death, the course is 
not always progressive, continuously advancing. This is evident from 
the large number of patients who give a history of hemoptysis, cough, 
fever, emaciation, pleurisy, etc., five, ten, or more years before the onset 
of the present illness, which was diagnosticated at the time as tubercu- 
losis, but the patient did well. For long years he had been able to 
attend to his work, only being laid up now and then for a few days with 
an attack of "bronchitis," "grippe," etc., but this last attack has 
proved persistent. Xow, if in this case a proper diagnosis had been 
made during any of the previous attacks, the prompt recovery would 
have been credited to the special treatment applied. In fact, many 
patients tell us that a certain prescription was very effective for years 
in relieving them promptly, but this time it has failed. 

All properly investigated statistical examinations have shown con- 
clusively that five years after the onset of active phthisis about 50 
per cent, of the patients are in good or fair physical condition and 
even able to make themselves useful at their respective occupations, 
irrespective of what method of treatment was applied. The statistics 
of results obtained in sanatoriums published by Lawrason Brown, 1 
Herbert Maxon King, 2 and others, show that patients discharged in 
the advanced stages of the disease are often found alive and active, 
five, ten, or even fifteen years later. A physician who keeps careful 
records and publishes a series of cases in which such results are shown 
can impress the profession that his method of treatment has done 
wonders. Yet it is just what should be expected under any method. 

A study of the literature on phthisiotherapy shows that nearly all 
authors, urging their methods, report certain and almost the same 
percentages of patients "cured," "disease arrested," "improved," 
"unimproved," and last, but always least, "dead." Practically all 
sanatoriums, whether located on high or low altitudes, at the sea- 
coast or inland, in cold, warm, or moderate climates; irrespective of 
the special method of treatment pursued — indoors, outdoors, or in 
tents; no matter what the fad or hobby of the attending physician, be 
it dietetic, medicinal, or specific; they all give the same results if we 
should judge them by the percentages of reported cures, improvements, 
and deaths as published in their annual report. 

During the first year or two after the introduction of new drugs or 
specifics, physicians report excellent results, as is seen from the litera- 
ture on creosote and arsenic and their derivatives, ichthyol, cinnamic 
acid, iodin, tannin, succinimide of mercury, etc. They all cured a 
certain percentage, arrested the disease in a larger percentage and 
failed only in very acute, progressive, or far-advanced cases. Phthis- 
iotherapy has thus been encumbered with an enormous number of 
medicaments which have been lauded by many competent and con- 

1 American Medicine, 1904, viii, 879; Ztschr. f. Tuberkulose, 1908, xii, 206. 

2 National Assn., Study and Prev. Tuberc, 1912, viii, 82. 



PSYCHIC INFLUENCES 533 

scientious physicians at one time or another, and condemned with 
equal vigor by others. According to Renon the popularity of each drug 
or method of treatment hardly exceeds three years. 

These are, in fact, the reasons why so many new methods of treat- 
ment, drugs, specifics, climates, diets, etc., are annually announced as 
curative agents for tuberculosis. They all depend on the normal pro- 
portion of recoveries which occur under any method. That charming 
French writer, Louis Renon, 1 says in this connection: "All new thera- 
peutic methods of treatment of tuberculosis, so long as they are harm- 
less, always give the same satisfactory results. This is an axiom which 
I should like to have printed with heavy type in all the new books on 
phthisiotherapy. It is an axiom which may be clinically translated 
into this simple statement: Hurry and take the treatment as long 
as it cures: if you wait you may be too late." 

The reasons for these therapeutic illusions are found in the above- 
stated facts. The disease is acutely progressive in comparatively few 
cases. In these, all agree that their remedies are of no avail and they 
are not counted in the reported cases. In a large proportion there is 
a strong tendency to spontaneous cure, and they furnish the recoveries 
for the special climates, specific and empiric therapeutic agents, for 
the "milk cures," the "song cure," the "grape cure," etc. In the 
majority of cases of active phthisis the disease runs an undulating 
course, with more or less frequent exacerbations of acute or subacute 
symptoms, followed by remissions in the activity of the process. In 
some the acute exacerbations are very infrequent, long remissions are 
obtained, the patient feeling comparatively well for several months 
and the credit is given to the method of treatment. 

Psychic Influences. — Persons under the influence of mild alcoholic 
intoxication are very susceptible to suggestion, and the consumptive 
who is under the influence of tuberculous toxemia is very vulnerable 
to auto- and heterosuggestion, as was shown in Chapter XIII. Any 
new drug, especially when boosted in the newspapers, is apt to relieve 
him in a remarkable manner. We often meet with consumptives who 
keep on sinking while under the care of a physician, but for some 
reason are impelled to change their medical adviser and, though the 
latter makes no changes in the treatment, the patient begins to gain 
in health and general well-being. This is usually the result of a new, 
careful, and minute physical examination by some pedantic physician 
who subjects his patient to all the diagnostic procedures — inspection, 
palpation, percussion, and auscultation; "gives him the benefit of the 
latest of diagnostic aids," the arrays, the cutaneous or subcutaneous 
tuberculin test, examines the sputum and urine in the presence of the 
patient, etc., and usually gives the same directions as those of the 
former physician, but more minutely; orders the patient to report 
frequently to see whether any changes are necessary. This is often 

1 Le traitement pratique de la tuberculose pulmonaire, Paris, 1908, p. 30. 



534 



THE INDICATIONS FOR TREATMENT OF PHTHISIS 







the beginning of a most remarkable improvement in a ease that has 
been going from bad to worse: The appetite returns, the cough ceases, 
the nightsweats disappear, etc., and he gains in weight and strength. 

Suggestion by Tuberculin Treatment. — There are many physio- 
therapists, competent to give authoritative opinion, who are convinced 
that tuberculin, as generally administered in minute doses, acts more by 
suggestion than by specific action on the tuberculous process in the 
lung. We shall revert to this subject while speaking of specific treat- 
ment. But meanwhile we want to point out the powers of suggestion 
in specific treatment as shown in a drastic manner by Albert Mathieu 
and Dobrovici, 1 who announced to the tuberculous patients at the 
Andral Hospital in Paris that a new discovery had been made, a 
new serum had arrived for the cure of tuberculosis, and that shortly 
a sufficient quantity of the remedy would be available for those in need 
of it. The patients had to wait for some time, and when the serum 
arrived they all rejoiced. The new remedy consisted simply of physio- 
logical salt solution, but was given the pompous name Antiphymose. 
Certain patients were told that they were fit subjects for antiphymose, 
while others were denied the treatment on the plea that it would not 
do them any good. The selected patients were placed under careful 
observation and their histories were again recorded minutely, so that 
all felt that they had been seriously given the first opportunity to 
benefit by a great discovery. No change was made in the surroundings 
of the patient and the diet, but all other medication was discontinued. 

The patients were greatly impressed by the new remedy and the 
favorable results exceeded all expectations. Within a couple of days 
there was noted an improvement in the appetite; those who had 
fever before showed a normal temperature, and the cough, expectora- 
tion and nightsweats were ameliorated; those who had hemorrhages 
ceased bleeding, and even the physical findings in the chest showed dis- 
tinct signs of amelioration of the process. The gain in weight was 
remarkable, ranging from 1500 gms. to 2 and 3 kilos. As soon as the 
injections were discontinued all the old symptoms reappeared. 

From personal experience 2 with the culture of turtle bacilli injected 
by Dr. F. F. Friedmann into patients under my care at the Monte- 
fiore Home in New York City, I can say that its effects were practic- 
ally the same as those of Mathieu's antiphymose. The heightened 
susceptibility to suggestion of the average consumptive was here 
vividly illustrated. No one will deny that the vast majority of people, 
healthy and sick, are amenable to suggestion in various ways, but it 
must be acknowledged that a group of patients suffering from acute 
or subacute gout or rheumatism, heart disease in a state of decom- 
pensation, of nephritis complicated by dyspnea and dropsy, of ulcer 
of the stomach, of cancer, or of any other organic pathological entity, 



1 Bull. gen. de therapeut,, 1908, cli, 882. 

2 Fishberg: Interstate Med. Jour., 1914, xxi, 349. 



PSYCHOTHERAPY IX TUBERCULOSIS 635 

would not be influenced to the same extent by suggestion as were the 
consumptives just mentioned. 

It appears that consumptives in all stages of the disease are 
susceptible to psychotherapy. I have repeatedly observed marked 
improvement in the subjective symptoms of patients who were told 
by their physicians that nothing could be done for them because they 
are doomed, while the new physician, who was promptly called because 
of the extreme prostration of the patients, assured the unfortunate 
sufferers that there was no danger at all, and that only careful treat- 
ment was necessary to rehabilitate the lost health and strength, and 
afterward a short visit to the country would enhance the chances for 
ultimate recovery. I have seen improvement in a patient after three 
punctures were made in her chest with a view of inducing an artificial 
pneumothorax, but no nitrogen was introduced into the pleura because 
of adhesions. Yet the temperature, which had been quite above nor- 
mal for weeks, promptly dropped to normal and the patient felt well. 
That tuberculous patients, as a rule, improve during the first few 
weeks or months in a new resort or institution is a well-known fact; and 
that it is usually not the superior climatic conditions or the different 
method of treatment that is efficacious in this respect is proved by 
their relapse into their former condition, or by the aggravation of their 
disease, after the novelty of the new surroundings begins to wear off. 
This is the main reason why climates "wear out." 

Psychotherapy in Tuberculosis. — This heightened susceptibility of 
the tuberculous patients to suggestion is of immense value and assist- 
ance to the physician who is the fortunate possessor of a personality 
which stands him in good stead when handling difficult and intract- 
able cases. But it is a double-edged sword. It also interferes in a 
large measure with the proper appreciation of the value of any thera- 
peutic procedure, because the patients are apt to be impressed with 
any new remedy, especially if it has been puffed up by an enthusiastic 
physician, and promptly improve. But the improvement is only 
short-lived, and within a short time all the old symptoms return, as 
we have shown. 

This psychic trait of the tuberculous is, however, of immense value 
in assisting physicians in their efforts to alleviate the more painful 
features of the disease, provided they know how to take advantage 
of it. Indeed, the success of many physicians in handling tuberculous 
patients depends on this point, and it is a fact that therapeutic nihilists 
fail, as a rule, to give relief to this class of patients. The detailed, 
often written, instructions given by physicians to their patients in 
sanatoriums, the minute doses of tuberculin administered, the vigilant 
anticipation of reactions, and the careful inquiry as to the effect on 
the constitutional symptoms, have all the elements of suggestive thera- 
peutics. Without these details, the institutional treatment of tubercu- 
losis, especially in private and costly sanatoriums, would be a failure. 

For these reasons the medicinal treatment of tuberculosis has a 



536 THE INDICATIONS FOR TREATMENT OF PHTHISIS 

place in the therapeutics of tuberculosis. The materia medica is of 
assistance not only in alleviating certain annoying symptoms, as we 
will show later on, but rational medication also imbues the patient 
with the idea that something is being done for him during his long and 
trying disease. Medicinal preparations are palliative, to be sure, 
but they often carry the patient over an acute crisis with more or 
less comfort which could not be obtained otherwise, and they stimulate 
a hopeful outlook for an ultimate recovery. 

The Indications for Treatment. — In the absence of specific remedies 
the therapeutic aims are to increase the natural forces of resistance of 
the tissues by constitutional treatment and by direct local treatment 
of the affected lung. The first indication is met by certain general 
therapeutic measures, the second by the induction of an artificial 
pneumothorax. In this book the treatment of phthisis is discussed 
with a view of methodically presenting the subject in the following 
order: 

1. General management of the case. 

2. Dietetic management of the case. 

3. Institutional treatment. 

4. Climatic treatment. 

5. Medicinal treatment. 

6. Specific treatment. 

7. Symptomatic treatment. 

8. Local treatment. 

9. Treatment of the various forms of tuberculosis. 
10. Treatment of the complications. 



CHAPTER XXXII. 
PROPHYLAXIS. 

The recent discoveries in the field of phthisiogenesis have shown 
that the prophylaxis of tuberculosis is much more complex than the 
simple formulae or programs of antituberculosis societies would indi- 
cate. A considerable part of the sure preventives given in popular 
and technical literature have been shown to be inefficacious or super- 
fluous by the newer teachings of the bacteriology, demography, and the 
clinical phenomena of this disease. 

Modern prophylactic measures should differ in accordance with 
what we aim at attaining. If our aim is to prevent infection with 
tubercle bacilli, we must take different measures from those which are 
indicated when we aim at preventing phthisis, the disease caused by 
these microorganisms. In our attempts at preventing tuberculosis in 
children we must resort to other prophylactic methods than when 
we aim at preventing tuberculous disease in adults. In fact, measures 
which are likely to prove effective in infants are not indicated in older 
children, while in adults most of the measures which have been found 
effective in early life are futile, extravagant, and even harmful. 

Prevention of Infection. — We have seen that the child is born free 
from tuberculosis, even if its parents are tuberculous at the time of 
conception or birth. We have also seen that during the first year of 
life some become infected and that the proportion showing signs of 
harboring tubercle bacilli in their bodies keeps on gradually increasing 
with advancing years so that at ten years the vast majority are in- 
fected, and that at the age of fourteen over 90 per cent, react to tuber- 
culin — an unmistakable sign of having been infected with tubercle 
bacilli. 

We have also shown that during the first year of life infection, if it 
does occur, is likely to result in an acute or subacute disease which 
proves fatal in nearly all cases. On the other hand, after passing the 
age of infancy infection becomes less dangerous, only rarely causing 
death, though it is liable, when localizing itself in glands, bones, and 
joints, to cause prolonged sickness and end in disfigurement, if the 
patient survives. 

Our main aim is therefore clear. The infant under two years of age 
must be protected against tuberculous infection at all costs. In 
families in which there is no tuberculous member this is a simple 
matter. Impressing the parents that infants acquire tuberculosis 
very readily, as easily as measles, scarlet fever, influenza, etc., and 



538 PROPHYLAXIS 

that a single exposure is liable to result in infection, they can, with 
reasonable and ordinary care, shelter their young offspring against 
the tubercle bacilli. Especially is this an easy matter with mothers 
who suckle their babies, and do not give them any cow's milk, so that 
bovine infection is entirely excluded. 

An infant is naturally not apt to come in contact with strangers 
unless those who care for it bring it in their proximity. Realizing that 
there are so many persons with open tuberculosis who are considered 
quite healthy, or who consider themselves healthy, "carriers" in the 
full sense of the word, it is obvious that in order to positively avoid 
infection at that age, infants must not be brought in contact with any 
one excepting the immediate family who are known to be free from the 
disease. 

But it must be remembered that the immediate family includes the 
grandparents, and they are often suffering from latent tuberculosis. 
The impression is gaining ground of late that a large proportion of 
the chronic bronchitis, pulmonary emphysema, asthma, etc., in aged 
persons, is of a tuberculous character, as was already shown in the 
chapter on phthisis in the aged. The writer in attempting to trace 
the source of infection has often found that it was the coughing or 
expectorating grandfather or grandmother who was responsible for 
the disease in an infant. 

Great care is to be exercised in selecting domestic servants for homes 
with infants. Especial care is to be taken with the nurse for an infant. 
She should be carefully examined by a physician, and reexamined if 
she acquires a "cold" that lasts more than a week. 

These simple measures suffice in homes in which there are no tuber- 
culous inhabitants. Xo infant should be allowed to remain in a home 
in which a phthisical person resides. Even if the patient is one of the 
most scrupulous, and takes excellent care of his sputum, he should not 
live in the same home in which an infant is raised. This is a point 
which, in our efforts to prevent the dissemination of the disease, is 
often overlooked. Following up phthisical patients, the authorities 
usually state that a careful consumptive is harmless, so long as he 
takes care of his expectoration, and permit tuberculous persons to 
live in the same home with infants. But as a matter of fact the harm- 
lessness of consumptives extends only to adults, and not because they 
are taking extreme care of their expectoration, but for other reasons 
which will be given later on in this chapter. As regards infants, no 
care, however conscientiously exercised, can surely prevent infection. 
And infection in infants is likely to prove deadly. 

The indications are therefore clear. Either the phthisical person 
or the infant is to be removed. Xo compromise can be allowed in 
such cases. 

Xo tuberculous mother is to be allowed to rear her young children, 
especially during infancy. It has been found that very few infants 
survive when suckled by a mother suffering from phthisis. The 



PREVENTION OF INFECTION ^39 

extensive statistics of Weinberg, 1 embracing 5000 families with 18,000 
children, have shown that the nearer the birth of the children to the 
time of death of their tuberculous parents, the higher the mortality 
among them. Three-fourths of the children born during the last 
year of life of tuberculous mothers succumb; and 90 per cent, 
of the children born during the last month of life of tuberculous 
mothers die. The investigations of the present writer 2 among children 
of tuberculous parentage in New York City have shown practically 
the same condition to prevail. In addition to the excessive mortality 
in general, 16 per cent, of the deaths among children under six years 
of age were due to tuberculous meningitis, as against only 1.27 per cent, 
among the general population of New York City. 

The prophylactic value of separation of the infant from its tuber- 
culous parents is well exemplified by experiences with tuberculous 
animals. Harlow Brooks 3 shows that in cattle the question of 
whether or not the offspring becomes tuberculous depends entirely 
upon exposure after birth. It has been conclusively shown that the 
calves are very rarely, if ever, infected before birth, but that the 
slightest carelessness in exposure of the newborn calves to infections 
leads to certain disaster. It has been found that tuberculous animals 
may be utilized for breeding purposes and that they may be crossed 
and inbred with entire disregard of the factor of tuberculosis and 
purely for the purpose of improving or maintaining the type, provided 
the calves are separated from the parents immediately after birth. 

Similar measures have to be taken in cases of newborn infants of 
tuberculous parentage. If the mother is tuberculous the infant is 
to be removed immediately after delivery, and should not be allowed 
in her proximity during the first two years of life. If the father is 
phthisical, he should be removed from the home so long as there 
are infants under two years of age. In some cases the alternative of 
removing the infant may be more feasible. Bernheim induced three 
tuberculous mothers who had twins -to separate with one child each, 
while retaining the others in their homes, though healthy wet-nurses 
were employed to suckle the babies. The three isolated children 
remained healthy, while the three which were raised at home suc- 
cumbed to tuberculosis. Armand-Dellile studied a series of 787 chil- 
dren born or living in 175 families one or more members of which 
were tuberculous. Of these children 323 were placed in the country 
and all did well; 396 were not removed from their tuberculous environ- 
ment, and of these 328 developed tuberculosis. Figures like these 
show how imperative it is to separate infants from their tuberculous 
parents more drastically than any other evidence. 

Available evidence tends to show that the infant is not infected 
through ingestion of the milk from its tuberculous mother, but through 

1 Die Kinder der Tuberkulosen, Leipsic, 1913. 

2 Archives of Pediatrics, 1914, xxxi, 96, 197. 
s Am. Jour. Med. Sc, 1914, cxlviii, 718. 



540 PROPHYLAXIS 

the bacilli she eliminates while speaking or coughing. Human milk 
is only rarely found to contain tubercle bacilli, so long as there is no 
tuberculous disease of the breasts. Stanley L. Wang 1 and Frederick 
Coonley examined the breast milk of 28 tuberculous women; speci- 
mens from 15 cases were injected intraperitoneally into guinea-pigs. 
In all cases the results were negative, no tuberculous changes being 
found in the animals at the autopsy; 450 microscopic examinations of 
specimens of milk were taken bi-weekly from the whole series of 28 
cases. These were all negative, excepting 1, which was positive once, 
and 1 other specimen from the same case, which was suspicious once. 
A. B. Marfan 2 reports similar experiences. He says that tubercle bacilli 
have only exceptionally been found in human milk. A few experiments 
have produced tuberculosis in animals by injecting them with milk 
taken from the breasts of tuberculous women. There are but two 
authentic reports of infants being infected by the milk of their mothers. 
These were the cases of Demme and Roger and Gamier. 

It is noteworthy that improvement in the sanitary and hygienic 
conditions, which are so effective in preventing phthisis in the adult, 
as will be shown later on, are not of any value in the case of infants. 
As has been pointed out by Romer, it was found that scrupulous atten- 
tion to hygiene and sanitation of the stable, such as proper construc- 
tion, ventilation, cleanliness, etc., hardly has any influence on the 
prevalence of tuberculosis in cattle, and that only strict isolation of 
the sick from the healthy animals is effective. Primary infection in 
infants appears to follow the same law: Exposure of an infant, even 
in an ideal home, may result in fatal tuberculosis, while life under 
adverse conditions will not produce tuberculous disease, unless there 
is a source of infection, which is usually the human consumptive and 
rarely milk derived from tuberculous cows. In the development of 
phthisis in adults hygienic and sanitary conditions play, however, a 
very important role. 

The prevention of bovine tuberculosis is not to be neglected. When 
an infant must be hand fed, the milk should be carefully selected. In 
large cities the only drawback is the cost. Certified milk is every- 
where available, but it is rather expensive and prohibitive for the vast 
majority of the population. For this reason all milk that is not derived 
from a source known to be safe is to be pasteurized or better yet, 
sterilized. Pasteurization does not always destroy all tubercle bacilli, 
as was shown by Hess. On the other hand, an investigation by E. C. 
Fleischner and K. F. Meyer, 3 in San Francisco, showed that in certified 
milk bovine tubercle bacilli w T ere not present in sufficient number to 
infect guinea-pigs. Certified milk is thus the safest for infants. How- 
ever, the main problem is the human bacillus, as was already shown. 

These simple measures are to be taken with a view of successfully 

1 Jour. Am. Med. Assn., 1917, hrix, 531. 

2 Le nourisson, 1916, iv, 34. 

3 Am. Jour. Dis. Children, 1917, xiv, 157. 



PROPHYLAXIS IN CHILDREN OVER THREE YEARS OF AGE 541 

preventing primary infection of infants under three years of age. 
They can be easily carried out by any family that has some degree 
of economic independence. In families which are to some extent ham- 
pered because of economic stress, the State is to interfere. Health 
Boards; which are busy protecting adults against infection to which 
they are hardly susceptible, could perform really useful service if they 
concentrated more and more along these lines. The mortality during 
the tender age of infancy, which has hardly been influenced by the 
campaign against tuberculosis, would be reduced to a minimum. 
Moreover, massive infection, which is apparently responsible for 
phthisis in the adults who have survived it during infancy, may thus 
be largely prevented. 

Prophylaxis in Children over Three Years of Age. — When the child 
begins to walk around and comes in contact with many people, pre- 
vention of infection is not simple. The parents, especially those who 
cannot afford a maid for each child — and they constitute the bulk of the 
population — lose control over their children, unless they are prepared 
to keep them altogether from contact with strangers, and this is not 
feasible for obvious reasons. Later when they go to school, they are 
bound to come in contact with other children and adults, and it is 
altogether impossible to prevent their meeting tuberculous individuals, 
no matter what the economic condition of the parents. It is thus clear 
that it is quite if not altogether impossible to prevent tuberculous in- 
fection among children over four or five years of age. 

But, as was shown in Chapter XXIV, infection in children over four 
years of age is usually relatively harmless. Either no disease at all 
occurs or rarely tracheobronchial adenopathy results, which is serious 
only in exceedingly rare instances. 

Available evidence tends to show that in infants infection is usually 
accomplished within the family — tuberculosis is exceedingly rare in 
infants who live in homes in which there is no phthisical member. 
When this is the case, we may trace the infection to someone living 
in the house as a lodger, or to some relative or friend who visits the 
home and comes in intimate contact with the infant, thus causing 
massive infection. With children of play and school age, the oppor- 
tunities for intimate contact with adult strangers are scarce; they are 
not taken in the arms, not kissed indiscriminately, etc., and even 
when infection takes place it is from another child, a playmate, etc., 
is slight, and not so massive as it is apt to be in infants, who are 
infected from adults. 

There is abundant clinical evidence of the relative harmlessness of 
infection of children over four years of age. One has but to consult 
the mortality returns in any country to convince himself that between 
three and fifteen years of age the mortality rates from tuberculosis 
are comparatively low, despite the fact that over 90 per cent, of the 
tuberculous infection of humanity takes place during this period of 
life. Comparing the results of infection during the first two years of 



542 PROPHYLAXIS 

life, and those taking place between four and fifteen years of age, the 
contrast is striking and convincing (see p. 389). Neither acute tuber- 
culosis nor chronic phthisis of the adult is common in children of 
school age. Thus, among 925,000 children examined by the medical 
school inspectors in New York City during the school year September, 
1914 to June, 1915, only 68 were found tuberculous. 1 When we bear 
in mind that each was examined by physicians and nurses once in six 
weeks on the average, and that a complete physical examination was 
made of all children three times during the course of the elementary 
school year, and that a cough noted by the teacher was sufficient to 
refer the child for examination, it is obvious that not many suffering 
from tuberculosis were overlooked. 

Under the circumstances, we may conclude that no matter what 
the cause is, infection of children during school age is comparatively 
harmless, and that, inasmuch as experience has taught that everybody 
is bound to be infected with tubercle bacilli, the best that can happen 
is that infection should occur at the age period of four to fourteen 
years. The primary mild infection at that age, as we have shown 
above, practically vaccinates humanity against more severe infections 
in later years. Otherwise, all adults would be as susceptible to tuber- 
culous disease as are guinea-pigs or the indigenous races of Central Africa. 

Our efforts are therefore to be directed next to the prevention of 
contact of infants with tuberculous persons; at the prevention of 
massive infection of children. This can be done within certain limits 
by preventing children from associating with individuals suffering 
from open tuberculosis. The danger lurks mostly in adults, because 
children expectorating tubercle bacilli are exceedingly rare. 

Prevention of Reinfection. — It thus appears that the bacilli infecting 
children remain dormant within the body and cause no disease so 
long as there are no predisposing or exciting causes. We know that 
under certain circumstances these dormant bacilli activate and cause 
disease by metastatic auto-infection. This is mainly seen in cases in 
which, owing to defective nutrition, or some intercurrent disease, 
notably measles, whooping-cough, typhoid, etc., the resistance is 
reduced, and an exacerbation of the tuberculous process takes place. 
Moreover, it appears that the younger the child, the more is the anergy 
thus induced likely to be followed by active tuberculous disease. The 
indications are therefore clear — young children and infants are to be 
sheltered against the endemic diseases. Special care is to be exercised 
in this direction with children of tuberculous parentage, who have in 
all probability suffered from massive infection. This class of infants 
is to be scrupulously shielded against measles, whooping-cough, scarlet 
fever, diphtheria, etc. If these diseases are bound to attack them, it 
is best that it should occur after thev have passed the fourth year 
of life. 

1 Weekly Bulletin of the Department of Health, City of New York, 1915, iv, 289. 



PROPHYLAXIS IN ADULTS 543 

During convalescence after one of these endemic diseases, the child 
is to be given special care with a view of preventing metastatic auto- 
infection while the body is in a state of anergy; in other words, sus- 
ceptible. This may be done by either taking the child to the country, 
preferably to the seashore, for a few weeks or months, till it has com- 
pletely recuperated; or, when it must be kept at home, it should be 
given proper nourishment and kept outdoors the greater part of the 
day, and it should sleep in a room with open windows. 

Prophylaxis in Adults. — Prophylaxis in adults is no more a problem 
of infection. It may be taken for granted that everyone who has passed 
through the first fifteen years of life, especially in a city, has been 
infected with tubercle bacilli. The fact that he shows no symptoms 
and signs of disease is no proof that he has escaped infection, as was 
already shown. In adults, the problem is the prevention of disease, 
of phthisis. I believe that a considerable portion of the inefficacy of 
the campaign against tuberculosis is due to the lack of appreciation 
of this distinction between infection and disease. 

This fact is based on the newer investigations in phthisiogenesis, 
which have conclusively proved two points : 

1. That chronic phthisis in the adult, of the type that creates most 
of the tuberculosis problem, never occurs immediately after a primary 
infection; if disease occurs at all soon after a primary infection, it is 
of the acute types of tuberculosis of the lungs or of other organs. 
Indeed, when disease follows immediately after a primary infection 
of an adult it is almost invariably deadly, as is seen in tuberculosis 
of primitive peoples who had not been exposed to infection during 
childhood. 

2. Infection with tubercle bacilli, whether it causes disease or not, 
renders the body immune against further and renewed exogenic infec- 
tion with the same virus. Inasmuch as nearly all adults have been 
infected with tubercle bacilli during their childhood, they are immune 
against reinfection with bacilli which may be eliminated by tuber- 
culous persons. The phthisical manifestations in adults are attributed 
to the infection during childhood, just as the tertiary manifestations 
of syphilis are late results of the original infection years ago, though 
the body is immune against renewed exogenic infection with the same 
virus. 

If this were not a fact, practically all the workers in hospitals for 
consumptives would succumb to the disease : all consorts of tuberculous 
persons would acquire the disease. One has to consider that of women 
married to, and living with, husbands suffering from active syphilis, 
hardly any escape infection. But we see thousands of tuberculous 
persons living with consorts, having children with them, yet the 
unaffected consorts remain in good health, as we have already shown 
in detail (see p. 123). 

It is therefore a vain effort to follow up tuberculous persons, push 
them from pillar to post, interfere with their employment, as has been 



544 • PROPHYLAXIS 

done in many cases, with a view of preventing infection of fellow- 
workmen. If these individuals cannot infect their husbands or wives, 
as the case may be, despite the intimate contact, they are surely not 
a menace to their fellow-workmen. 

This fact is now beginning to be recognized by those who are well- 
informed about the recent progress in our knowledge of phthisiogenesis. 
There has been manifesting itself a reaction against the absurd and 
cruel phthisiophobia which has been rampant for about twenty-five 
years. Baldwin 1 says: "Adults are very little endangered by close 
contact with open tuberculosis, and not at all in ordinary association. 
. . . It is time for a reaction against the extreme ideas of infec- 
tion now prevailing. There has been too much read into the popular 
literature by health boards and lectures that has no sound basis in 
facts and it needs to be dropped out and revised." 

Prevention of Phthisis. — It appears that in the eager chase after the 
bacteria, which could never be entirely destroyed, we have forgotten 
that only a small portion of those infected develop phthisis, while 
the rest are apparently benefited by the infection. Some recent 
writers have not hesitated to apply the term benevolent infection to 
those who have been fortunate in acquiring tuberculosis during later 
childhood and have thus been immunized against primary infection 
after fifteen years of age, when the disease produced by a primary 
infection is apt to run an acute and fatal course. Otherwise, we 
would all succumb to the acute and fatal forms of tuberculosis. 

Phthisis is a disease occurring in persons who have been infected 
with tubercle bacilli many years before the outbreak of the disease. 
It is due to reinfection. But available evidence appears to point in 
the direction that the reinfection occurs from within, that it is metas- 
tatic; the bacteria which have remained dormant for years are slowly 
or suddenly reawakened into activity, and they produce new lesions; 
and that exogenic reinfection is exceedingly rare, if at all possible. 

We know that certain conditions favor a reduction in the normal 
resisting powers of the body and permit the proliferation of the dor- 
mant bacilli. Among these, inferior sanitary, hygienic, and economic 
conditions stand out preeminently. We have seen that the rates of 
wages, the number of rooms in which a family lives, the character 
of the work pursued by an individual, etc., have a strong influence in 
the direction of enhancing or preventing the evolution of phthisis. For 
this reason, the philanthropic agencies may do more toward the 
prevention of phthisis by concentrating their attention on improve- 
ments along economic lines of reform than by sending agents to tell 
adults that it is dangerous to remain in the proximity of a consump- 
tive. Labor unions do better by exacting higher wages and shorter 
hours than driving unfortunate phthisical persons from their places of 
employment, as is being done of late in New York City, 

i Johns Hopkins Hosp, Bull., 1913, xsiv, 220. 



PHTHISIOPHOBIA 545 

Phthisiophobia. — Phthisis is undoubtedly an exacerbation of dor- 
mant tuberculous processes in the lungs; its entire clinical course is 
undulating, with periods of quiescence interrupted by periods of 
activity. These acute and subacute exacerbations may be prevented 
by careful attention to the general health of any individual who shows 
the least tendency to phthisical disease. Such individuals should not 
be hounded, refused employment, etc. They are to be helped along in 
the direction of securing easy work during the quiescent periods, so 
that they may be self-supporting and self-respecting. The words of 
an intelligent and observing consumptive on this subject are to be 
borne in mind by social workers, who of late seem to know more of the 
etiology and prevention of tuberculosis than those who have made a 
special study of the subject. Says the American historian, William 
Garrot Brown, in his Confessions of a Consumptive: 

"The public depends for protection from such danger as our con- 
tinued existence involves, not on its own exertions but on ours. To 
render that protection we must burden ourselves with both expense 
and trouble. We must incessantly take, for the sake of the public, 
precautions which are disagreeable and costly ; and meanwhile a great 
part of the public is, by its attitude toward us, steadily tempting us, 
and even sometimes fairly compelling us, if we would live to discon- 
tinue these precautions and go on as if there were nothing the matter 
with us. The folly and stupidity of this attitude it is impossible to 
overstate. It is of itself by far the chief cause and source of the per- 
sistence of this scourge. 

"Known and recognized and decently entreated, we are not dan- 
gerous. Shunned and proscribed and forced to concealments we are 
dangerous. Victims ourselves of this same regime of ignorant and self- 
deceiving inhumanity, we are called on every hour of our lives for a 
magnanimous consideration of others. Society can hardly find it 
surprising or a grievance if our human nature should sometimes weaken 
under the strain of the incessant provocation it endures from this 
strange working of human nature in general. Why should we alone 
be expected to be guiltless, always to our own cost and sacrifice, of 
that very form of man's inhumanity to man from which we ourselves 
are suffering more than anybody else? Yet I can honestly attest that 
the vast majority of us are guiltless of any merely resentful offense; 
that, as a rule, when we fail to protect the public it is only because 
the public compels us to disregard its interest, its safety. This is what 
I earnestly entreat the public, for its own sake, candidly to consider. 

"Candidly means fully. If the public is to be safe froin us, if the 
public is to continue to have our protection from that against which 
it failed to protect us, then the public must make it possible for us 
to get — it must certainly cease to make it impossible for the mass 
of us to get anything except by subterfuge — what we must have to 
live. We are neither criminals nor mendicants. We do not ask favors, 
we merely revolt against a mean and stupid oppression. We revolt 
35 



546 PROPHYLAXIS 

against ignorance and against a lie. The public would get rid of us, 
and thereby makes us inescapable. It would pretend, and would have 
us pretend, that we are nowhere. It thereby insures that we shall 
be everywhere. It proscribes us and thereby admits us." 

If the average consumptive was not shunned by adults; if he was 
permitted to work unmolested after he is cured or the disease is arrested, 
or quiescent, allowing him to earn his livelihood, a considerable part of 
the economic stress caused by this disease would be done away with. 
If the tuberculous individual is told that he is only a menace to infants, 
less dangerous to children, and not at all dangerous to adults, he will 
surely take all precautions against infecting those who may be harmed 
by it. 

But at present the State, municipal, philanthropic and social agencies 
that send out representatives telling those who live with consumptives 
that the patients must be shunned, and incidentally conveying the 
information that a careful patient, i. e., one who takes care of his 
sputum, is not at all dangerous, even to infants. Some patients in Xew 
York City are actually dreading lest their names will be reported 
to the authorities, and they will be pestered by those well-meaning 
nurses, physicians, social workers, etc. Instead of telling the patient 
that he is only a menace to infants, and that he must keep away from 
them, they often visit his place of employment and the result is that 
the unfortunate patient is soon: without a job and starving. 

The results of these methods of phthisiophobia are seen in the 
fact that the number of infants which succumb to tuberculosis has 
not decreased even in Germany where antituberculosis agencies have 
been most active; that the number of persons infected with tubercle 
bacilli has not decreased is clear when we consider that over 90 per cent, 
of humanity react to tuberculin. 

I do not want to be understood as speaking unfavorably of all pro- 
phylactic measures against tuberculous infection of adults. There are 
many, especially among the richer classes in cities, and in suburban 
and rural districts, who have escaped infection during childhood, and 
they should be protected. It is, in fact, well known that tuberculosis 
when occurring in these classes is often of an acute type, just as it is 
in the indigenous races of Central Africa or in the Esquimaux. They 
should be protected against the sputum indiscriminately expectorated 
by consumptives, and against droplet infection when coming in con- 
tact with persons suffering from active phthisis. But with the city- 
bred people, especially those who have survived in the congested parts 
of cities or the slums, there is hardly any danger that adults will be 
infected with tubercle bacilli. They have been infected during child- 
hood; vaccinated and immunized against additional infection. But 
it is just among these that the strong efforts are made to prevent 
exposure of adults to infection. The irony is that their infants are 
usually neglected by the social forces working in the antituberculosis 
campaign. 



DISPOSAL OF THE SPUTUM 547 

Just as cattle breeders have found that the control of tubercu- 
losis is mainly a matter of prevention of infection of newborn calves, 
and that adult cattle may be disregarded, so must we act with humans. 
To prevent infection, newborn infants must be protected while chil- 
dren over ten and adults need no special measures, especially those 
who have been raised in cities. 

Disposal of the Sputum. — In our attempts at preventing infection, 
the disposal of the sputum expectorated by phthisical patients is more 
important than any other prophylactic measure. The saprophytic 
bacilli are distributed in a virulent form only from one animal body to 
another. Exceptionally, the source of the bacilli is a domestic animal, 
mainly milk from tuberculous cows, but in the vast majority of cases 
the source of infection is sputum expectorated by phthisical patients. 

For this reason the rigorous laws prohibiting indiscriminate expec- 
toration which enlightened communities have inaugurated are fully 
justified, and they ought to be more rigorously enforced. It should be 
made clear that tuberculosis is not the only disease which is trans- 
mitted by expectoration, but many other diseases may be thus 
transmitted, so that nobody ought to spit on the floor of a house or 
public place. Furthermore, there are many tubercle bacillus " carriers" 
who do not suffer from the disease which they are liable to transmit, 
especially to infants and children. The fact that indiscriminate expec- 
toration is prohibited irrespective of the question whether the offender 
is tuberculous or not, makes it easier to exact it from the phthisical 
patients, who do not like to be stigmatized. 

In the case of children, especially infants, it is not only sputum which 
is dangerous, but also the droplets flying out of the mouth and nose 
during the acts of coughing, sneezing, and talking. For this reason a 
consumptive should not associate with infants, even if he is careful 
with his expectoration. Droplet infection may prove disastrous to 
infants. In the case of adults, coughing and sneezing are hardly dan- 
gerous. We have already mentioned Saugman's conclusion that it 
is not dangerous for adults to be coughed at by a tuberculous patient 
(see p. 123.) 

Cuspidors. — The disposal of the expectoration is therefore an impor- 
tant problem, and it has been suggested that the best means of rendering 
it harmless is that it should invariably be deposited in some form of 
cuspidor. 

Floor cuspidors in rooms, especially in public places, are a nuisance; 
they cannot be tolerated 'in any decent home for both sanitary and 
esthetic reasons. They are unsightly, and just as much of the sputum 
is often deposited around the vessel as within it. Flies, cats, and dogs 
are frequent visitors, and with mouths or legs covered with sputum may 
proceed further in their quest for food, and deposit the bacilli on food 
which is subsequently used by the inhabitants of the house. The 
elevated cuspidors, of which we find such beautiful illustrations in a 
certain variety of books on tuberculosis, may be good for certain 



548 



PROPHYLAXIS 






institutions, especially those harboring advanced consumptives, but 
they should not be, and are not, used in homes and public buildings. 
They are also an invitation to spit; they provoke expectoration in 
persons who otherwise would not do it. This is the reason why they 
are hardly seen anywhere, except in books and in institutions. 

The pocket sputum flasks are objectionable for other reasons. Their 
variety is great, if we are to judge by the large number illustrated in 
popular books on the prevention of tuberculosis. The ingenuity of 
the designers or inventors is noteworthy and could have been used 
to better advantage in other directions. They are, however, not used 
outside of institutions to any noticeable extent. I fancy that a per- 
son who would take out a sputum flask, even one of those which 
look like cigar boxes, lunch boxes, etc., and spit into it within the 
sight of people in a public place, would create a miniature panic 
among some who have read popular literature on the prevention of 
tuberculosis. 

They are objectionable for another reason. No matter how wide- 
necked they are made, the patient must apply his lips to the mouth 
of the flask if he wants to deposit the sputum within it. The result 
is that part of the sputum sticks to the lips or mustache and beard, 
and this must be removed with a handkerchief. Even if all male 
patients would consent to shave clean it would not help. I have 
observed that the lips are very often covered with sputum after the 
patient has expectorated into any of these flasks. 

In institutions they should be used, and the ones made of pasteboard, 
kept in a tin frame-holder, are the best. Patients in the advanced 
stages of the disease should use them at home in case they expectorate 
large quantities of sputum. 

But I can see no reason for urging them on patients in the incipient 
stages of the disease, expectorating but little sputum. Physicians 
trying to imitate legislators who pass laws which they know cannot 
be enforced, defeat their own ends. We cannot induce a patient to 
carry a sputum flask with him, no matter how fine and deceptive its 
construction may be, and to use it in public. I have also known some 
patients in the incipient stages of the disease who left sanatoriums 
because they could not tolerate their fellow-sufferers walking around 
with sputum cups in their hands. Advanced patients are hardened 
in this respect, as a rule. 

Patients in the incipient or quiescent stages of the disease can 
empty their chests in the morning into cuspidors containing some 
cheap disinfectant. It should soon be emptied into the water-closet. 
Urging them to burn it is usually a vain effort, if only because there 
are no facilities in modern homes for the purpose. Those expectorating 
considerable quantities may efficiently dispose of their sputum by the 
use of paper napkins. Toilet paper will also answer the purpose. 
Several thicknesses are folded once, so as to receive the sputum; the 
paper is again folded and the ends folded over so as to enclose the 



DUTIES OF COMMUNITY IN PREVENTION OF PHTHISIS 549 

expectorated material, and then placed in a grocer's bag (about 6 by 
12 inches). The bag can be pinned to the side of the bed, or clamped 
to the small bed-table. Several times a day, depending on the amount 
of sputum, the bag and its contents should be burned, if there are facili- 
ties for the purpose. The folded paper pockets containing the sputum 
may, however, be disposed of by dropping them singly into the water- 
closet and flushing it immediately. 

There is no question that there are valid objections to the handker- 
chief, though it is not so strong a menace as some writers would lead us 
to believe. But the average patient will use nothing else for reasons 
already stated. Portable sputum cups are used only in institutions 
and in homes, but, despite the agitation in their favor, we fail to meet 
persons in the streets or public places of any large city in the world, 
carrying and expectorating into them, although we know that thou- 
sands of consumptives are everywhere. Even if it is a compromise, 
we must submit to the inevitable and permit patients to use handker- 
chiefs. It is best that they should be made of gauze or cheap cotton, 
which may be destroyed after use; or they may be of Japan paper, 
which may be deposited into the water-closet which is immediately 
flushed. If made of better material, the handkerchief should be boiled 
before washing. Boiling is a better and surer bactericide, especially 
of tubercle bacilli in sputum, than any chemical disinfectant. 

Duties of the Community in the Prevention of Phthisis. — In its 
demands on the consumptive to shape his life in such a manner as to 
prevent the dissemination of the disease, the community must not 
neglect its own duties to the unfortunate individual, who is suffering 
to a great extent because of conditions which the authorities have 
permitted to prevail. The community must not only provide shelter, 
proper nourishment and medical attendance for those patients who are 
not in a position to procure it at their own expense, but must also see 
to it that the conditions favoring the development of phthisis should 
be eliminated. 

Laws regulating the sanitary and hygienic conditions of dwellings 
for the working people, among whom the proportion of phthisical 
patients is high, should be passed and rigorously enforced. Tenement 
house laws, passed and enforced, have a greater influence on the reduc- 
tion of the morbidity and mortality from consumption than all the 
lectures delivered in and out of season to social workers, policemen, 
teachers, and workmen, on the perils of the tubercle bacilli and the 
best means of killing them. The demolition of the old-style tenements 
with numerous rooms without windows has saved many more per- 
sons from developing phthisis than all the sanatoriums which are 
supposed to isolate the sources of infection, but which, in fact, exclude 
those in the advanced stages and permit them to come into intimate 
contact with infants and children. The abolition of the sweat-shops 
in New York City deserves more credit for the prevention of phthisis 
than all the leaflets which have been distributed by so many over- 



550 PROPHYLAXIS 

lapping agencies, each eager to get at the persons who cotigli as a 
result of tuberculosis or some other disease and "follow them up." 

Light and well-ventilated dwellings and workshops are of prime 
importance in preventing phthisis, and the community in which there 
are no rooms without windows and no sweat-shops or factories which 
are dark and badly ventilated has the least consumptives to care for. 

Good wages and short hours, allowing good nourishment, and time 
for outdoor exercises and recreation, are important in the control of 
phthisis. 

Marriage of the Tuberculous. — The problem of marriage is one 
which the physician often has to solve for his patients. We frequently 
have to answer the question whether a non-phthisical consort should 
continue to live with the phthisical partner; or whether a tuberculous 
patient, in any stage of the disease, may enter the married state. 
Answering these questions involves a consideration of several factors: 
The dangers of transmission of the disease to the non-phthisical con- 
sort; the dangers to the potential offspring; and the effect of the 
married state on the patient. 

The dangers of transmission of the disease to the consort are negli- 
gible. We have brought statistics proving that the unaffected consorts 
of consumptives are no more liable to become phthisical than others of 
the same age and social condition (see p. 123.) The unaffected consort 
has undoubtedly been infected during childhood, and reinfection is not 
likely. Whether he or she will develop phthisis depends on factors 
other than reinfection from the patient. The conclusion is therefore 
justified that, as regards transmission of the disease alone, there is 
no more danger in marriage of phthisical patients than in cases of can- 
cerous or diabetic patients. Our answer is to be about the same as 
when two persons who had both been previously infected with syphilis 
ask whether they are permitted to marry. 1 

The danger to the children that may result from the union is enor- 
mous. If the newborn child will remain in the proximity of the phthis- 
ical parent, it will most likely become infected during infancy and 
succumb. Under the circumstances, unless they are satisfied to 
remove the child immediately after birth and not see it till it has passed 
the first two years of life, phthisical patients should not procreate. 
This is a point which cannot be emphasized too strongly to tuberculous 
patients who are married or contemplate marriage. It is especially 
dangerous for an actively phthisical woman to raise infants. They 

1 In this connection it is interesting to cite the following lines from Metchnikoff : 
"At the age of twenty-three," he says, "I married a young lady of the same age who 
was attacked by grave pulmonary tuberculosis. Her condition of feebleness Was such 
that it was necessary to carry her in a chair in order to mount the few steps which led 
to the church where our marriage was to be celebrated. . . . My wife died of tuber- 
culosis after four years of suffering. I passed the greater part of that time by her side 
in the greatest intimacy without taking any precaution against the contagion; never- 
theless, in spite of these conditions, which were especially favorable for catching the 
disease, I have remained free from tuberculosis, and that during forty-four years since 
my marriage." (Bedrock, January, 1913.) 



MARRIAGE OF THE TUBERCULOUS 551 

will, we can say almost without exception, acquire the disease and 
succumb during the first year of life. 

The effects of the married state on the patient are different in men, 
as compared with women. On the average male patient in the 
incipient or moderately advanced stages of the disease, sexual inter- 
course has the same effect as on the average person who is not in per- 
fect health. If he indulges moderately, it does him no harm at all; in 
fact, it may be beneficial because it prevents brooding over enforced 
abstinence which is often seen among all classes of men. It also pre- 
cludes venereal complications which may have an effect on the 
phthisical process. 

With women, things are different. So long as they do not become 
pregnant there are no strong and valid reasons against married life. 
In fact, among the working classes the married consumptive woman 
is better situated than the single who soon after becoming tuberculous 
also becomes a dependent; and if she has no family to care for her, 
she is doomed. But pregnancy, childbirth, and lactation are functions 
which are of grave augury for a consumptive woman. Occasionally 
we see that during the pregnant state the tuberculous process in the 
lung improves, and the general condition of the patient is strikingly 
ameliorated. But in the vast majority of cases, soon after childbirth 
there is an acute or subacute exacerbation of the disease and the 
patient succumbs within a few months. This fact has also been 
observed in domestic animals. In cattle parturition is frequently 
followed by generalization of a local tuberculous process and speedy 
decline and death, as has been observed by Theobald Smith. 1 

Married tuberculous women are therefore to be given detailed 
instruction on the proper methods of prevention of conception. If 
they become pregnant the induction of abortion is indicated and justi- 
fied both for the sake of the prospective child, which is bound to 
become tuberculous unless removed from the proximity of the mother 
immediately after birth, and for the sake of the mother, who is liable 
to succumb to acute or subacute tuberculosis soon after childbirth. 

The demands made by some enthusiastic advocates of eugenics that 
tuberculous persons should be prohibited by law from marrying, has 
no scientific basis in view of what has been stated above. The race 
is not in danger of deterioration because of children derived from 
tuberculous stock. We have already mentioned that tuberculous 
cattle have been used for breeding purposes by removing the calves 
immediately after birth. We see no reason why this should not hold 
in human beings. Moreover, prohibition of legal marriage does not 
exclude extramarital sexual intercourse and childbirth with their 
concomitants. Free instruction on the means of prevention of con- 
ception is more likely to eliminate phthisical stock, and thus prove of 
eugenic value, than prohibition of marriage. 

1 Jour. Amer. Med. Assn., 1917, lxviii, 672. 



552 PROPHYLAXIS 

On eugenic grounds it has also been stated that tuberculosis is rather 
a benefactor of humanity. It removes the weakly, the decrepit ; in short, 
the unfit. In time, it is thus argued, all the susceptible will thus be 
removed and the race will improve. But we have seen that it is not 
only the weakly and decrepit which are likely to be attacked. The 
large number of athletic youths who develop tuberculosis in the prime 
of life prove that the strong suffer as often as the weak; the enormous 
number of intellectual giants who have succumbed to tuberculosis 
(see p. 258) show that humanity would be the gainer by eradicating 
tuberculosis. 

A patient presenting himself or herself with the problem of mar- 
riage should be explained the situation along the lines just detailed 
and if he or she is intelligent, we may rest assured that the action will 
be reasonable for both the married couple and the community. The 
ignorant and reckless will not consult us in such matters and if they 
do, they will not follow instructions. For this reason, they should be 
left out of consideration in discussions of this kind. One thing I always 
insist on with my patients: The unaffected partner must be informed 
about the true state of affairs and given the choice. Very often it 
will be found that a good woman will greatly help along a consump- 
tive toward a recovery which could not have been attained if the 
patient had remained single; or that a female patient will recover 
after marriage to a man who gives her a good home, proper food, etc. 



CHAPTER XXXIII. 
GENERAL MANAGEMENT OF THE CASE. 

Should the Patient be Told that He is Tuberculous?— The diagnosis 
of pulmonary tuberculosis having been definitely made,, there arises 
the question whether the patient should be told the true nature of 
his disease. Many physicians are inclined to keep him in ignorance 
as to the true state of affairs, and to tell him that he is merely affected 
with a "mild bronchial catarrh," "pleurisy," "a protracted cold," 
etc. Very often a patient is brought to the office by relatives and 
friends who beg the physician that in case tuberculosis is diagnosti- 
cated, the patient should under no circumstances be told the truth. 

There are many valid reasons against such a procedure. From the 
standpoint of the physician's personal interest, it is bad practice. It 
is always to be borne in mind that the patient will, sooner or later, 
find out the truth and blame his doctor for deception or, more often, 
accuse him of ignorance and claim, with considerable justice, that had 
he been informed in time he might have taken Fetter care of himseliT 
~~But there are reasohs~6f more importance than the doctor's interest 
for telling the truth to every patient on such occasion. It must never 
be lost sight of that tuberculosis is transmissible, particularly to 
infants and children, and that the patient must be warned against 
the possibility of disseminating the seeds of the disease. This can 
only be done by telling the patient the true state of affairs, and giving 
him details of the principles of prevention. Moreover, the average 
patient knows that, in many cases, the chances of recovery diminish 
with the advance of the disease, and negligence in informing him of 
his opportunities at the earliest possible time may prove disastrous. 
We do not know of any quick cures, and the cooperation of the patient 
is absolutely essential. He can only take proper care of himself and 
those around him when he knows the true situation. 

It is noteworthy that relatives and friends who have requested a 
physician to keep the patient in ignorance of the fact that he is tuber- 
culous are always grateful in the end when he is tactfully informed of 
the truth. 

Irrespective of requests of friends and relatives, the patient is to 
be told plainly and unequivocally that he suffers from tuberculosis. 
In really incipient cases this can be done in several instalments, because 
it usually requires several examinations to make a positive diagnosis. 
But when finally told, it is to be emphasized that he is in the incipient 
and curable stage, and assurances given that in his case the prognosis 



554 GENERAL MANAGEMENT OF THE CASE 

is very favorable. But it must be insisted upon that the patient's 
cooperation is absolutely essential to attain a cure. An intelligent 
patient may be given details of the nature of the disease and it may 
be pointed out that his own determination to follow instructions is of 
more importance than all the medicines and climates; in fact, with- 
out his own cooperation, he is lost even if he consults the best known 
specialists, enters the most famous sanatorium, or emigrates to any 
climatic resort. It is a striking fact that nervous and excitable patients 
who are expected by their relatives to break down on hearing the 
truth, resign themselves to their fate and often display courage and 
determination worthy of heroes. 

"Unless we carry conviction to our patients," says Arthur Latham, 1 
"they are unlikely to put up with the restrictions which are inevitable 
to proper treatment. It is a disastrous thing to talk about a "weak 
spot" in the lung. It is our duty, in an overwhelming proportion of 
cases, to state his position frankly to the patient, to explain intel- 
ligibly the reasons for the treatment prescribed, and the possible pen- 
alties which may have to be faced if our advice is neglected. If we 
can convince our patient, we shall in all probability have won his 
loyal cooperation, which is half the battle; if we fail to convince him 
or get him to see the reasonableness of our advice, we cannot expect to 
find treatment carried out with sufficient earnestness and consistence 
to be of real value." 

The suggestion has been made by Penzoldt 2 that the dose of truth 
given to the patient should be in inverse ratio to the seriousness of 
the case— the less the chances of recovery, the smaller the dose of 
truth. In incipient and hopeful cases the whole truth is best, but 
the term "consumption" should be avoided in all cases; "tuberculosis" 
is a term which covers everything for the patient, though as we have 
seen, it is not exactly correct scientifically or clinically. But in the 
popular mind it has been of late considered a hopeful and curable 
disease, if taken in time. Some patients may be told that when 
neglected, "tuberculosis" may turn into consumption. 

As Abraham Jacobi 3 well says: "When a patient strikes a doctor 
who recognizes a human being in the forlorn creature before him he 
is told that he has tuberculosis. When he addresses a young colleague, 
an immature colleague, a colleague satisfied with and gratified by the 
possession of a diploma and who likes to exhibit his knowledge and 
authority, he is told he has "consumption." "You have tuberculosis. 
If it were to get worse it would run into consumption. But cases 
of tuberculosis may and often do get well, so there is no reason for 
despair." 

It is different with advanced and hopeless cases. They present 
themselves asking whether their cough is really due to consumption 

1 Practitioner, 1913, xc, 38. 

2 Handbuch der Therapie, 1910, iii, 205. 

3 American Medicine, 1905, x, 1063. 



RELATION OF PHYSICIAN TO PATIENT 555 

and it is at times a pity to tell the unfortunate patients the true state 
of affairs; not unless we are not averse to shortening their days. Still, 
for obvious reasons it is always imperative that some relative or 
friend should be told the truth. Similarly, in cases of acute or 
subacute pulmonary tuberculosis, or in progressive cases with com- 
plications, such as those suffering from diabetes, tuberculosis of 
the kidneys, etc., in addition to the active pulmonary lesion, it is 
often advisable to console the unfortunate and doomed patient if he 
likes it, by telling him that the prognosis is excellent. 

Economic and Social Conditions.— In outlining the treatment to be 
pursued, the social and economic condition of the patient are always 
to be borne in mind. It is not advisable to tell a patient of limited 
means that a certain private sanatorium, or a climatic resort in a distant 
part of the country, is good for him. He is likely to brood over the 
fact that owing to his poverty he is lost, when in fact he could get 
along very well at home or in the neighborhood of his city. Well- 
to-do patients may be sent out of town with only suspicious symptoms 
and signs of the disease on the principle of some physicians to treat all 
"suspects" as tuberculous until proved to be free of the disease. The 
rest during the vacation does them good; in fact, they usually need 
it. But patients with limited means should never be treated in 
this manner. In them only a positive diagnosis of tuberculosis should 
be the criterion for radical and costly treatment. 

Relation of Physician to Patient. — A great deal has been written 
about the relation of the physician and his tuberculous patient and 
it has been repeatedly stated that the former must possess certain 
qualifications which, if taken seriously, would exclude 99 per cent, of 
practitioners from the category of physicians competent to handle an 
ordinary case. According to one writer, the physician must possess 
no less than an extraordinarily strong personality, immense will-power 
to impress it on his patients, unusual teaching ability, fervent enthu- 
siasm and unremitting interest, etc., if he is to meet with success. 

Evidently these requirements are such as all ideal physicians should 
possess if they are to be fit for successful practice. The truth is that 
in most cases it is quite easy to gain the confidence and cooperation 
of the patient, if this is at all obtainable. The main problem is to 
retain it for the long period of time it takes until the termination of 
the case. This is especially true of chronic phthisis which runs an 
undulating course with accidents (hemorrhages, fever, anorexia, etc.) 
which come and go unexpectedly, and are liable to shatter the most 
implicit confidence. This is one of the reasons why tuberculous 
patients, next to those suffering from venereal diseases, are the best 
prey for quacks and charlatans. 

My observations lead me to the conviction that the average tuber- 
culous patient can be easily managed and his confidence retained for 
an indefinite time when we appeal to his reason. It is a grave mistake 
of many superintendents of public sanatoriums who try to obtain the 









556 GENERAL MANAGEMENT OF THE CASE 

cooperation of their patients by keeping them in constant fear of 
punishment — expulsion. As one patient told me, the superintendent 
inflicted severe punishment on patients for small infractions of the 
rules of the institution because for these dependent patients the only 
hope of recovery was the sanatorium. Such severity does not at all 
help along in gaining the confidence of patients. I know of public 
sanatoriums in which the patients are always coerced into obedience 
of the rules and to submitting to prescribed treatment, but they do 
not discharge the proper proportion of cured patients, and a very 
large number leave the institutions of their own volition before the 
physicians discharge them. 

To a certain extent the patient treated by his physician at home 
is more amenable to reason than those in public sanatoriums. The 
physician in private practice is in a position to individualize his cases 
and more easily persuade them that their only chances for recovery 
lie in their implicit obedience to orders. When the patient is told 
the reason why we want him to rest the greater part of the day for 
weeks or months; why we want him to eat certain kinds and quanti- 
ties of food; why we want him to submit to the operation for artificial 
pneumothorax, etc., he is more likely to submit than when we threaten 
him. All this can be done with alleged ignorant patients, who usually 
have more common sense than they are credited with, as well as with 
the intelligent and cultured. In fact, the former are, as a rule, more 
tractable than the latter. We must always remember that these 
patients make great sacrifices for months, and need consolation and 
encouragement which only the reasonable physician is able to 
bestow. 

Personal Hygiene. — The first instructions given to the patient are 
as regards his personal hygiene. This can best be done only after 
careful inquiry into his daily habits which, as a rule, are found not 
to have been exemplary; otherwise he would not have been likely 
to develop phthisis. To be successful, it is necessary to enter into 
the smallest details of every-day life and most patients appreciate 
it greatly. 

Treating patients in cities, after deciding against a sanatorium, it 
is of immense importance to ascertain their home surroundings. A 
call should be made at the house of the patient to see whether it is 
fit for a tuberculous individual, and especial attention should be paid 
to the location of the sleeping room, its size, windows, exposure, etc. 
In case these are not found satisfactory, moving should be urged, 
preferably to the outskirts of the city or a suburb. Details are given 
in Chapter XXXV. 

In our attempts at adapting the patient's mode of life to the thera- 
peutic indications, we meet with great obstacles when trying to im- 
press him with the urgency of cessation of work, physical and mental, 
and it is particularly difficult to persuade patients with mild lesions 
showing few constitutional symptoms. They are convinced that work 



PERSONAL HYGIENE 557 

does them no harm. The poor point to the necessity for providing 
for themselves and those dependent on them, while* the well-to-do 
are apt to be even more intractable in this regard. They must not 
neglect their business, they must finish some task they have under- 
taken, they are deeply absorbed in some studies; they must continue 
at college until graduation, etc. But the careful physician is not 
moved by these pleas and points out to the patient that just because 
he is in such good physical condition the prognosis is so good. But 
should he continue working physically or mentally, the disease will 
surely make inroads on his vitality and the chances of ultimate and 
complete recovery will vanish. Whether he "leaves" the city or not, 
the patient may be induced to take a complete vacation with all the 
separation from the activities of life a vacation entails, but without 
any of its pleasures. The details about rest and exercise are given in 
Chapter XXXVI. 

Baths. — The mortal fear for " colds" entertained by many is accen- 
tuated as soon as the diagnosis of tuberculosis is made and one of the 
first results is that the patient ceases to bathe. In many advanced 
cases, or even in incipients who suffer from profuse nightsweats, large 
patches of pityriasis versicolor are to be seen on the skin of the neck 
and trunk. When told that bathing will remove it, women are easily 
induced to take frequent baths. But all are to be instructed that 
bathing improves the circulation, activates the skin, and invigorates 
the individual. It must be insisted upon that the patient bathes 
frequently and follows it up by vigorous rubbing of the skin with a 
rough towel. 

The question of cold baths in tuberculosis has been very much 
debated. In some institutions, cold baths and frictions are the chief 
elements of the cure. They are urged for the purpose of hardening 
the body against colds. But many are not fit for the purpose of 
hardening; they do not react properly and, instead of feeling refreshed 
and invigorated after a cold bath, their extremities are livid, benumbed, 
chilled, and they feel altogether miserable. These patients, indepen- 
dent of their physical condition, are better off when taking only warm 
baths, twice or thrice weekly, followed by frictions. The statements 
of some that every tuberculous patient can be subjected to a process 
of hardening, if methodically applied, does not hold as is evident 
from the fact that it is not pursued systematically in most sanatoriums. 
Bed-ridden patients may be sponged with tepid, or even cold, water 
during febrile attacks with great benefit. Patients who have been in 
the habit of taking cold baths, douches, or sponging, every morning 
should continue to do so during their illness, but those who do not 
bear these procedures well should only bathe in warm water, as was 
just stated. 

Robust patients may also be allowed swimming within reasonable 
limits; bathing outdoors, especially sea bathing, is good for quiescent 
cases. Turkish and Russian baths are decidedly harmful in active cases. 



558 GENERAL MANAGEMENT OF THE CASE 

Clothing. — The tuberculous patient should be sensibly clothed; the 
aim being to keep him warm during the cold winter, but not over- 
heated. The fear for "colds" is responsible for the excessive under- 
wear which we often find on patients, and, coupled with the several 
vests, sweaters, coats and overcoats, they are often fairly borne down 
by the weight of their clothing. The well-known red flannel pad, " the 
chest protector," has not as yet been abandoned after all the medical 
agitation against it; we often see patients wear them and every drug 
store sells them. Not only do the poor and ostensibly ignorant classes 
make use of them but we meet them among so-called educated patients. 
They become habituated to this excessive covering of the chest, and 
perspire freely. When they attempt to remove it they are easily 
chilled, which is responsible for many of the catarrhal complications 
which occur during the course of the disease. 

In the beginning of the treatment, the patient is to be discouraged 
from such practices. He is to be told with due emphasis that woolen 
underwear, of thickness consistent with the season of the year and other 
meteorological conditions, is all that is necessary. A woolen garment 
has a capacity for absorbing considerable moisture without feeling 
wet, while cotton soon becomes saturated with moisture. If evapora- 
tion takes place suddenly, the body is chilled. Some patients are 
unduly irritated by wool next to the skin, but by constant wear they 
overcome this difficulty. Of course, it is important that the underwear 
worn during the day should not be worn during the night 

All sudden changes in temperature within and out of the house are 
to be met by changing the overgarments. During the winter a fur 
coat is good, and can be purchased for about the same price as a good 
overcoat. Those taking outdoor treatment on a reclining chair need 
extra wraps during the Winter. Carrington 1 gives a complete descrip- 
tion of the various appliances which may be used for the purpose. 

Women are less easily managed in regard to clothing than men. 
The low cut around the neck and chest is very harmful to tuberculous 
women, and they are to be induced to forego some of the fashions in 
vogue. But what is of most importance is the corset which many 
refuse to part with, claiming that it is not at all the figure they care 
for, but that they have been habituated to stays and feel uncomfortable 
without them. But when explained in detail the way a corset, even of 
those called "hygienic," interferes with the respiratory movements 
of the thorax, most women submit to the argument. 

Smoking. — The problem whether a patient who has been found 
tuberculous should give up smoking has troubled many physicians 
in sanatoriums. Some have been inclined to prohibit it indiscrimi- 
nately and failed, as a rule. One who has been habituated for long 
years to smoking cannot easily give it up and when he does he is 

i Journal of Outdoor Life, 1912, ix, 262. 



PERSONAL HYGIENE 559 

often so nervous and miserable that it has an immense influence on 
his general well-being and the course of the disease. The fact is that 
smoking has no deleterious influence on the tuberculous process in the 
lungs, and there is no reason for imposing an additional hardship on 
the patient. Of course, chewing tobacco should be prohibited. 

The assumption that smoking predisposes to tuberculosis and 
aggravates the pulmonary condition if indulged in by tuberculous 
individuals, has been shown to be incorrect. Gerald B. Webb, 1 in a 
statistical investigation, found that of a comparatively large number 
of soldiers in the United States Army, the proportion discharged from 
active service because of active pulmonary tuberculosis was no higher 
among those who smoked than among those who did not. His con- 
clusion that inhalation of the smoke of cigars or cigarettes does not 
predispose the lungs to tuberculous disease thus confirms this fact 
which has been long ago observed by clinicians. Webb, however, 
found that but few non-smokers have rhonchi, or sibilant rales, while 
the majority of smokers do present these signs of bronchial irritation. 
But as has been pointed out by Krause 2 in this connection, inflamma- 
tory processes have not been found to be predisposing factors for 
bacterial infection; it may rather be considered as a factor in the 
resistance against infection. William S. Duboff 3 found that tobacco 
does not predispose to laryngeal tuberculosis, and that throat com- 
plications are no more frequent in tobacco users than in those who 
use no tobacco. Laryngitis, of specific character or not, appears to 
be equally common among women as among men in the course of 
pulmonary tuberculosis, showing that tobacco is not an important 
factor. 

When there are laryngeal complications smoking is apt to cause 
irritation and cough. However, I am inclined to follow Fetterolf's 4 
suggestion: The patient, if he craves for his cigar, cigarette, or pipe, 
is thus instructed : " The smoke is not to be blown through the nose or 
inhaled; that if a cigar or cigarette is used it shall be smoked in a 
holder at least four inches long, and, finally that the smoking be 
done in the open air. The main evils, barring excess, are dry heat 
and dust which are drawn into the pharynx and larynx. This is of 
greater significance the shorter the smoked article grows, and if the 
cigar or cigarette is used in a holder and only the first half is smoked, 
this evil is largely done away with." It is Fetterolf's belief that with 
such precautions as just mentioned and with the smoking done in the 
open air, no harm will result. A non-smoking patient in a close 
room with others smoking is at a greater disadvantage than one who 
is smoking in the fresh air. 

1 Am. Rev. Tuber., 1918, ii, 25. 

2 Ibid., p. 99. 

3 Ibid., ii, 21. 

4 Hare's Modern Treatment, ii, 405. 



560 



GENERAL MANAGEMENT OF THE CASE 



Occupations for Arrested Cases of Tuberculosis. (W. J. Vogeler.) 



Healthy. 


Unhealthy. 


Healthy. 


Comparatively 
healthy. 


A 
Because of 


B 
Factors connected 


C 

To employer, etc. 




occupation. 


with occupation. 




Artificial flower 


Attendant in in- 


Auctioneer 


Brewery hand 


Baker 


maker 


sane asylum 


Brakeman 


Detective 


Butcher 


Banker 


Bowling-alley at- 


Bridge builder 


Dyer 


Candymaker 


Barber 


tendant 


Caisson worker 


Emery-wheel 


Child's nurse 


Bone-carver 


Boxmaker 


Canvasser 


worker 


Cook 


Bookbinder 


Braider 


Car conductor 


Garage 


Druggist 


Bookkeeper 


Brass worker 


Cigarmaker 


Gasworks em- 


Fish cleaner 


Bootblack 


Bricklayer 


Coalyard em- 


ployee 


Grocer 


Broker 


Brickmaker 


ployee 


Glassblower em- 


Hairdresser 


Broom-maker 


Cap maker 


Collector 


ployee 


Ice-cream vender 


(broom and 


Carpenter 


Compositor 


Hotel and board- 


Iceman 


brush maker) 


Carriage maker 


Constable 


ing-house keep- 


Ice manufacturer 


Business man 


Cementer 


Courier 


ers 


Milkman 


(merchant and 


Chemist 


Driver 


Laboratory em- 


Nurse 


dealer, retail 


Chicken-farming 


Drayman 


ployee 


Nurses (trained) 


and wholesale) 


Electrical worker 


Horseman 


Livery stable 


Midwife 


Butler 


Elevator employee 
Fireman (fireman 


Teamster 


keepers 


Oysterman 


Buttonhole maker 


Engineer 


Marble worker 


Seamstress 


Cabinet-maker 


and engineer) 


Expressman 


Miner 


Spice-room worker 


Chair-caner 


Gasfitter 


Farmer 


Pool-room atten- 




Chambermaid 


Glazier 


Hostler 


dant 




Clergyman 


Gold preparer 


Huckster 


Printer 




Clerk (clerk and 


Harness maker 


Inspector 


Rag-sorter 




copyist) 


(saddle maker 


Iron worker 


Reporter 




Cloth examiner 


and repairer) 


Janitor 


Riveter 




Cooper 


Houseworker 


Junk dealer 


Sailor 




Coppersmith (cop- 


Lamp cleaner 


Letter carrier 


Saloon and restau- 




per worker) 


Laundry worker 


Lineman 


rant keepers 




Cutter 


(male and fe- 
male) 
Masseur 


Longshoreman 


Scissors-grinder 




Decorator 


Lumberman 


Stage hand 




Designer (archi- 


Mechanic 


Lumber-yard 


Stone-cutter 




tect, designer, 


Mill hand 


employee 


Tobacco workers 




and draughts- 


M older 


Messenger boy 


Type-polisher 




man) 


Oilworks employee 


Miller 


Typesetter 




Dressmaker 


Operator 


Motorman 


Woolsorter 




Engraver 


Packer 


Mover 


Wine dealer 




Embroiderer 


Paperhanger 


Musician 






Factory hand 


Penmaker 


Navy employee 






Foreman (mill) 


Pipe-cutter 


Newspaper vender 






Gardener 


Plasterer 


Newspaper work 






Hatter (hat and 


Plaster-of-Paris 


Painter 






capmaker) 
Jeweler 


worker 


Peddler 






Rubber-maker 


Plumber 






Labeler 


Sawyer 


Policeman 






Labor boss 


Seamstress 


Porter 






Laborer (labor 


Statue-painter 


Pressman 






not specified) 


Steamfitter 


Raftsman 






Lawyer 
Leather worker 


Stereotyper 
Terra-cotta worker 


Rigger 
Salesman 






(currier and 


Tin-roofer 


Saleswoman 






tanner) 


Trunkmaker 


Scrubber 






Librarian 


Waiter 


Shipper 






Lithographer 


Washerwoman 


Shipwright 






Locksmith 


Wheelwright 


Signalman 






Machinist 




Soldier 






Merchants and 




Steel worker 






dealers 




Stevedore 






Metal worker 




Stoker 






Milliner 




Street-cleaner 






Morocco finisher 




Street-paver 






Nickel-plater 




Tool-sharpener 






Office-boy 




Undertaker 






Officials of com- 




Vine-grower 






pany 
Oilcloth worker 




Veterinarian 








Watchman 






Optician 




Window-cleaner 






Photographer 




Wood-chopper 






Physicians and 










surgeons 










Picture-frame 










maker 










Presser 











PERSONAL HYGIENE 561 

Occupations for Arrested Cases of Tuberculosis— Continued. 



Healthy. 


Unhealthy. 


Healthy. 


Comparatively 
healthy. 


A B C 
Because of Factors connected To employer, etc. 
occupation. | with occupation. 


Servant 

School-child 

Shirtmaker (shirt 
and collar and 
cuff maker) 

Shoemaker 

Springmaker 

Stand-keeper 

Stenographer 
(stenographer 
and typewriter) 

Storekeeper's em- 
ployee 

Student 

Suspender maker 

Tailor 

Teacher (teacher 
and professor 
in college) 

Telegraph opera- 
tor (telephone 
and telegraph) 

Telephone opera- 
tor (telegraph 
and telephone) 

Time-keeper 

Tin-plater (tin- 
plate and tin- 
ware worker) 

Tinsmith 

Truss-maker 

Upholsterer 

Violin-maker 

Watchmaker 

Weaver 

Woodworker 











Occupation. — A great deal has been said of occupations fit for tuber- 
culous patients. The problem is not one which concerns those with 
active disease, but the convalescents, as w T ell as those who have recov- 
ered. A patient during the active course of phthisis in any stage 
should have no occupation at all. He cannot work, he must not attend 
to any vocation which requires physical or mental exertion. Mis- 
takes are often made in permitting patients in the incipient stages to 
wind up their business, to finish a course in a school, etc. This is 
a point which will be discussed later on w T hile speaking on rest and 
exercise and cannot be emphasized too strongly. 

It is very difficult to advise patients who have recovered from 
phthisis as to their future activities in the affairs of life. With the 
rich and prosperous the matter is very simple : They may be allowed 
to return to their vocations provided they know how to take care of 
themselves. Under supervision, and with careful observation of the 
ordinary rules of healthy life, they very often avoid relapses. The same 
is true of professional people w T ho can resume their life work, perhaps 
at a slower pace. But with those w T ho have been artisans, manual 
laborers, etc., especially in "precarious occupations," the matter is 
different. It is, indeed, easy to advise one to change his vocation, 
36 



562 GENERAL MANAGEMENT OF THE CASE 

as is done in sanatoriums when patients are discharged, but whether 
the patient is more harmed by working at his trade and earning for 
his support, than by starvation because of lack of funds to buy food, 
pay for his lodging, etc., is hard to decide. 

Moreover, a change of occupation is not feasible in the vast major- 
ity of cases, especially with skilled artisans. They cannot easily 
accept low wages when at their own trade the pay is much higher, 
and the hours shorter. It is also a fact, only rarely considered by 
medical men, that the artisan has usually adapted his organism to his 
peculiar occupation; in fact, there is a process of selection going on, 
certain persons are attracted to certain trades at which they succeed. 
They must return to these occupations after recovering from the 
disease, if they are at all to be able to support themselves. And they 
do, in fact, in spite of our protestations. 

But we must try to keep convalescing tuberculous patients from 
hard muscular exertion, if relapses are to be avoided. They are to 
be under medical supervision for several months after beginning 
to work, and if they show any signs of damage to their constitution, 
especially fever, dyspnea, tachycardia, etc., they must stop before 
it is too late. Nor should a cured patient be allowed to work at any 
dusty trade, such as pottery and earthenware manufacture, cutlery 
and file making, certain departments of glass making, copper, iron, 
lead and steel manufacture, stone cutting, textile trades, fur- or cigar- 
making, iron-grinding, etc. We have seen the effects of organic, 
mineral, and metallic dust in the direction of engendering a soil suscep- 
tible to phthisis. When we bear in mind that a patient with cured 
tuberculosis almost always harbors virulent tubercle bacilli in the cica- 
trized area of the lung, we can easily understand that irritating dust 
may at any time flare up a dormant lesion into renewed activity or 
cause metastasis. 

Special efforts should be made to find outdoor employment for 
patients cured from tuberculosis. It is always to be remembered that 
farming is not the only outdoor work, nor is it the best. Farm labor- 
ers usually work very hard for long hours, small pay, and with food 
that does not satisfy the city dweller. In addition, as has been pointed 
out by Vogeler, 1 the lack of amusement during the hours of recreation 
and the enervating heat during the summer are serious drawbacks. 
Of course, it is different when the patient can raise funds to buy or 
lease a farm for himself. 

There are in cities many more or less remunerative occupations 
which are suitable for this class of cases, as conductors, motormen, 
ticket agents, attendants at ferries, watchmen, solicitors, etc. My 
observations lead me to the conviction that workers at the garment 
industries, excepting at fur, may safely return to their occupations, 
provided they find employment in light and well-ventilated workshops. 

i Trans. Nat. Assn., Study and Prev. Tubeic, 1912, viii, 113. 



PERSONAL HYGIENE 553 

The same is true of the building industry, provided the exposure to 
the vicissitudes of the weather is not excessive nor the hours too 
long; and of clerks, salespersons, etc. Indeed, I have been struck 
with the fact that when a patient who recovered from phthisis is 
unable to pursue the vocation for which he has been trained for many 
years, he will not do well, even if he remains idle indefinitely. 

In advising tuberculous convalescents about occupations, the fact 
must not be lost sight of that we know very little about the subject. 
We have shown that only certain kinds of dust predispose to phthisis, 
while others, on the contrary, apparently confer more or less immunity 
against the disease. Among the latter may be mentioned coal dust, 
lime dust, etc. (see p. 111). The same is true about the problem of 
indoor as compared with outdoor occupations. When we find that 
hotel servants have a very high mortality from tuberculosis, it does 
not necessarily mean that it is because of their indoor work. On the 
one hand the work, not involving strong muscular exertion, attracts 
weaklings, and then also they are liable to drink excessively. Street 
sweepers are apparently spared by tuberculosis to some extent, but 
their outdoor occupation also involves the inhalation of dust exces- 
sively. I have seen very few tuberculous patients among the workers 
in the underground subway of New York City despite the fact that they 
are employed in an indoor occupation par excellence. The same has 
been noted in London. Cobbett 1 mentions that the old underground 
railway in London, before it was electrified, was considered as a par- 
ticularly favorable place for consumptives. The stations of Portland 
Road and Gower Street, which were entirely below the surface of the 
ground, and which were formerly notorious for their mephitic vapors, 
were regarded as the best for tuberculous patients, and the authorities 
transferred to these stations any of their workers who showed signs 
of incipient tuberculosis. The problem of "indoor," as compared 
with "outdoor" occupations is thus seen not to be as simple as some 
believe it is as regards tuberculosis. 

The list of occupations, compiled by Dr. W. J. Vogeler, and repro- 
duced on p. 560, may be consulted when considering a suitable 
occupation for a convalescing or cured patient. 

In judging a patient with a view of selecting an occupation for him, 
we may be guided by the condition of his temperature, pulse, respira- 
tion, and general constitution, but the extent of the lesion is a hazard- 
ous criterion. All who have had experience agree with H. M. King 
that "it frequently happens that a satisfactory condition of health 
as determined by restoration of working efficiency maintained for many 
years is not incompatible with physical signs which of themselves 
would indicate active disease." I have seen many cases in which the 
reverse was true, the patient showed no signs of active disease in the 
lung, yet as soon as he began to work he broke down with fever, rapid 

1 Causes of Tuberculosis, London, 1917, p. 98. 



564 GENERAL MANAGEMENT OF THE CASE 

pulse, dyspnea, etc. These patients cannot work at all. Then there 
are others who will work for several months and, owing to an evanes- 
cent, acute, or subacute exacerbation, are laid up for several days or 
weeks. With these it is very difficult to judge the ability to work. 
All tuberculous patients, even after completely recovering from the 
disease, find it difficult to compete with healthy persons, but the 
class just mentioned is more apt to lose in the struggle for existence. 
They must find for themselves employment of a nature which makes 
them independent of strict regularity. 

On the luhole, it appears that cured patients do best when return- 
ing to their old vocations for which they have been trained, and at which 
they can earn the most with the least possible effort. It may be said that, 
with some striking exceptions, if a patient is not able to pursue his former 
line of work he is altogether disabled. 



CHAPTER XXXIV. 
THE REST CURE. 

Principles of the Rest Cure.— We know that Nature makes a strong 
effort at repairing the affected lung in tuberculosis, but we only rarely 
think of the method it pursues when doing it. Examining the chest of 
a tuberculous patient, we find on inspection that there is a strong 
tendency to putting the affected area of the lung at rest. As already 
has been shown, during the early stage the muscles overlying the 
pulmonary lesion are almost invariably rigidly and spasmodically 
contracted. This contraction has been ascribed by Rubel 1 to the 
physiological coordination of the respiratory center. It inhibits or 
prevents the motion of the underlying lung to a certain extent. Later, 
pleural adhesions are formed which impede the respiratory movements 
of the lung to a yet greater extent, as is seen in the lagging of the 
affected side of the chest, offering favorable conditions for cicatriza- 
tion. This immobilization of the affected part of the lung also slows 
the circulation of blood and lymph in that area retains the bacteria 
and their toxic products, thus lessening toxemia and preventing 
metastatic auto-infection of unaffected parts of the lung. Rubel has 
shown experimentally that functional rest greatly contributes toward 
a cure of tuberculous lesions in the lung. He immobilized one lung 
in rabbits and then infected them by the intravenous way. In the 
relatively immobilized lung the lesion was found to be of the chronic 
and favorable variety, while in the freely movable lung it was acute 
and progressive. 

Surgeons have utilized physiological and functional rest in the 
treatment of tuberculosis of bones and joints. The modern treatment 
of Pott's disease and tuberculosis of the various joints consists mainly 
in affording rest to the affected parts. The splint has done better 
than the knife in these forms of tuberculosis. Formerly physicians 
aimed at procuring rest in tuberculous diseases of the thoracic viscera 
by the application of strips of adhesive plaster, thus immobilizing the 
thorax; and at present the induction of an artificial pneumothorax 
puts the affected lung at complete functional rest. " In breathing, a 
normal person 'opens and shuts' the lungs nearly 30,000 times a day," 
says Webb. "By rest we aim to make the breathing as shallow as 
possible, imitating almost that of hibernating." 

In febrile cases rest has a rationale which is clear to ^ everyone who 
gives some thought to the subject. Fever is an indication of activity 

1 Ztschr. f. Tuberk., 1908, x, 193, 319; Roussky Vratch, 1907, vi, 648, 721, 750, 896. 



566 THE REST CURE 

of the tuberculous process and results from absorption of toxins. By 
keeping the patient at rest we reduce the frequency and depth of 
respiration and thus less of the toxins are washed into the blood 
stream and the fever declines. With the reduction in the fever there 
is an amelioration in the cough and an improvement in the appetite, 
resulting in better nutrition of the patient. 

Rest and Exercise in Phthisis. — In former days the treatment of 
tuberculosis consisted mainly in removing the patient to some country 
place, or better yet, to an institution, and urging him to exercise in the 
open air. Thus, the main principles of the treatment in Brehmer's 
sanatorium were outdoor exercise for long hours, daily walking, driv- 
ing, horseback riding, mountain climbing and respiratory exercises. 
The same methods were followed in institutional and home treatment 
by many physicians until about twenty years ago. 

The deA'elopment of sanatoriums in which careful observations 
have been made on the effects of these exercises on tuberculous 
patients has resulted in swinging the pendulum, and rest has come 
to the foreground as the most important factor in combating the 
disease, so that at present vigorous protests are heard from many 
sides that the indolent life led by sanatorium patients is often more 
harmful for various reasons than the exercise which was formerly in 
vogue. Indeed, Paterson reports just as many cures at Frimley where 
the patients do graduated work, as in sanatoriums in which they are 
kept at perfect rest for long months or even years. 

The contradictory evidence in favor of rest or work is evidently 
due to the fact that neither rest nor exercise is a panacea which will 
help in every case, but that each has its indications and contra-indica- 
tions. When patients presenting symptoms of active and progressive 
phthisis— fever, anorexia, emaciation, etc. — are urged to work or 
exercise, considerable harm is often done, and a favorable case may 
thus be converted into one which is decidedly hopeless. In the 
later stages of the disease, when the lesion has localized itself and 
the patient has no fever, eats well and feels strong enough to do some 
work, perfect rest may be distinctly harmful, as will be pointed out 
later on. Rest and exercise have their indications and contra- 
indications. 

Indications for Rest. — Nature puts most patients who suffer from 
active and acute forms of the disease at rest. They are weak, anemic, 
emaciated, and the exhausting cough, the dyspnea, and the phenom- 
ena of toxemia in general, preclude any kind of exercise. But in the 
chronic cases, or even in some of the subacute cases, the patient may 
not realize his plight and continue working at his occupation until 
he breaks down, when it is too late to recoup the lost flesh and forces. 
Rest, properly applied, in this class of cases may be life saving. 

It is clear that all active cases with fever, tachycardia, anorexia 
emaciation, weakness, etc., are to be kept strictly at rest until most 
of these symptoms have disappeared. But it must be stated at the 



REST AND EXERCISE IN PHTHISIS 567 

outset that the extent of the lesion is no reliable criterion as to the 
indications for rest and exercise. A patient in the incipient stage, with 
a limited and circumscribed small lesion at one apex, and suffering 
from fever, dyspnea, anorexia, etc., is often more harmed by work 
or exercises than one in the advanced stages, with extensive involve- 
ment of both lungs, but with normal pulse and temperature. 

With but few exceptions, the rate of the pulse is as good an index 
of the fitness of the patient to work as there is. So long as it is 90 or 
over per minute, or it is accelerated to that rate by mild exercises, the 
prognosis is not good unless the patient is kept at perfect rest. In 
tuberculosis we often meet with unstable tachycardia; the pulse runs 
up to 120 or more per minute at the least exertion or excitement. 
,Sucb patients are to be kept in bed, or on the reclining chair, until we 
find that mild exercise, like walking slowly on level ground for a half 
or one mile, does not unduly accelerate the pulse. Some of these cases 
with tachycardia are afebrile, the temperature is in fact very often 
below normal, and exercise may not affect it, but the pulse is accel- 
erated on the least exertion. 

Dyspnea, when present, is another sign that the patient must be 
kept at rest. We must be guarded and not wait for subjective dyspnea, 
because many tuberculous patients have adapted themselves so well 
to their difficulties in breathing that they are not much disturbed 
by it, and when seen to breathe very superficially and rapidly, even 
more than thirty times per minute, they may inform us that they 
suffer no inconvenience in this respect. It is objective dyspnea which 
should guide us in our estimation of the effects of rest or exercise in 
tuberculous patients. 

Fever has been considered an indication for rest by most writers 
on the subject; in fact, the problems of exercise and rest have usually 
been solved by the thermometer. In cases of tuberculosis in which 
the temperature reaches 100° F. the patient is put to bed, and kept 
there until it descends to normal. In acute cases, with continuous fever 
or during acute exacerbations in chronic cases, or when some compli- 
cation ensues, such as pleurisy, or any non-tuberculous infection, 
complete rest is enjoined until the fever abates. In far-advanced cases 
with hectic fever, reaching a high degree in the afternoon or evening, 
and dropping to normal or even below in the early morning hours, 
the patient is to be kept in bed at absolute rest. There are, however, 
cases of tuberculosis with fever which do not require strict rest. They 
are discussed in detail elsewhere, while speaking of the treatment of 
fever. 

Technic. — The rest cure, when indicated, is to be carried out 
methodically. In acute progressive cases it means complete rest in 
bed until the temperature declines to below 100° F. Some patients 
revolt, saying that they feel strong enough to walk around for several 
hours of the day, that they are lonesome and would surely improve 
if they were permitted to assume the erect position for some time. 



568 THE REST CURE 

But they are to be told that fever cannot be cured outside of the bed, 
and as Poujade said: "Undoubtedly prolonged rest in bed weakens 
a patient, but it weakens less than fever which kills." 

In the home of the patient it is advisable, when feasible, to have 
two beds, in one of which he sleeps during the night, and in the 
other he spends the day. Considering that the patient may have 
to remain in bed for weeks or months, the enforced solitude is hard 
on him, and the change of the bed has some salutary effect. More- 
over, these patients are apt to sleep during the day and suffer from 
insomnia during the night. By changing the room and bed they often 
become habituated to sleep in one bed and remain awake during the 
day in the other. One room and bed may also be aired while the 
other is used. 

In the morning, when the patient wakes, he is to be given a sponge 
bath — one with alcohol is invigorating — and dressed, the lower half 
of the window opened and the bed placed in such a position that he 
can look out on the living world. If he feels cold, a hot-water bag may 
be placed at his feet. Great care must be taken to prevent bed-sores 
in prolonged and advanced cases. 

When the temperature descends below 100° F., or even in prolonged 
cases when it reaches this degree only at a certain time in the afternoon, 
but is near normal during the rest of the day, the patient may be 
kept at rest on a reclining chair during the greater part of the day, 
preferably outdoors, and reading and mild games may be allowed; 
only during the hours when the rise in temperature is expected is he 
to be made to go to bed. When we find that this does not increase 
the fever, he may be permitted mild exercises, such as short walks, 
and the effects should be watched. We are often surprised to find 
that the fever disappears altogether with mild exercises. 

This rest in bed is at times very difficult to carry out. The poor are 
often working for weeks while the temperature is high — I have seen 
them working with fever of 103° F. and even higher. When beyond 
control in this regard, the patient is to be sent to an institution, or 
to one of the day and night camps. I have seen excellent results in 
such cases after the patient has been at one of these institutions 
for a few months. Not only has the fever disappeared, but the patient 
was educated to appreciate the dangers of exercises during the febrile 
stage. But the w T ell-to-do are not better in this respect. Very often 
we find them walking around, and even dissipating, in spite of the 
fact that their temperature is above 102° F. Indeed, they are often 
less amenable to reason in this respect than the poor. They are to be 
impressed that all business and pleasures are to be given up when the 
temperature is high. 

Contra-indications. — It was one of the great mistakes of many sana- 
toriums to urge all patients to keep at perfect rest and abstain from 
work or exercises, irrespective of the form of the disease and the 
constitutional symptoms. The result was that they turned out lazy 



EXERCISE 569 

people — hypochondriacs — who feared work and who at the least 
fatigue considered themselves harmed by it after they had been cured. 
In most sanatoriums of today strong efforts are being made to avoid 
such mistakes. 

As was already stated, the extent of the lesion is not always an 
index as to the indications for rest. There are many patients with 
extensive lesions in the lung, in fact with large excavations, who are 
well able to make themselves useful along certain lines. Indeed, there 
are cases in which prolonged rest is distinctly harmful. The nervous 
system may be functionally damaged beyond repair, the desire for 
activity may be stifled, and the resistance of the body in general may 
be lowered. It has also been suggested by Paterson and Inman that 
prolonged rest deprives the patient of certain reactions which bodily 
activity calls forth in the pulmonary lesions and which are of great use 
in combating the deleterious effects of the disease. 

In some sanatoriums where the rest cure has been carried to 
excess we often meet with patients who, after remaining in bed or 
on the reclining chair for several months, become mentally tired and 
listless; they lack interest in current affairs; others - become hypo- 
chondriacs, consulting the thermometer several times a day and are 
alarmed at each finding above or below normal. They often lose all 
hope of ever getting cured and this despondency contributes greatly 
to the unfavorable course of the disease. 

The graduates of sanatoriums in which the rest cure is carried to 
excess are apt to be lazy for the rest of their lives. Some of them, 
discharged from one institution, immediately seek admission to another. 
As Herman M. Biggs says: "A sick workman is converted into a 
healthy loafer." They fear muscular exercise of any kind and imagine 
that the least work aggravates their condition. In the State and 
municipal institutions in this country we find many with a record 
of having been in several sanatoriums. In fact, prolonged rest dis- 
ables any human being, because the muscles become stiff and any 
attempt to walk produces muscular weakness, pains and aches in 
the limbs. In some, the long rest favors the deposition of fat, which 
is very encouraging, but when carried to excess, which is not a very 
rare phenomenon among the tuberculous, it may disable the patient 
as much as active phthisis. These patients must have exercises to 
reduce the fat. This is mainly seen in patients in whom the disease 
may or may not be active, but at any rate is not progressive; the lesion 
has become quiescent, completely surrounded by connective tissue. 
Rest may only produce obesity of various degrees, but does not assist 
in the healing of the disease focus in the lung. It is in these cases 
that graduated work or any exercise will do more than rest, and 
McLean's aphorism "if the phthisical patient would live, he must 
work for it," is confirmed. 

Exercise. — When the temperature and pulse become normal and 
remain so for several days, walking exercises are to be commenced, 



570 THE REST CURE 

with a view of preventing the deleterious effects of idleness, as well 
as provoking mild reactions — auto-inoculations, which are, in most 
cases, of immense benefit. At first the patient is allowed to walk a 
mile on level ground and the effects on the temperature and pulse are 
watched. It may be done during the morning hours, when the tem- 
perature is normal, while in the afternoon, when there is some fever, 
the patient is ordered to rest on a reclining chair, or even in bed. But 
in those in whom the afternoon temperature is mild, below 99° F., 
even this precaution need not be taken, provided the pulse is below 
85 per minute. 

The following schedule for walking exercises, modified after that 
given by E. Hyslop Thomson, 1 may guide the patient who takes his 
own temperature : 

{ 98.5 or lower; long or medium walk. 
Morning temperature I 99. 0; short walk. 

at 7 a.m. ) 99.5; rest outdoors or short walk around house. 

100. or higher; remain in bed. 

99.0 or lower; medium or short walk. 
Temperature at noon \ 99 . 5 ; short walk. 

100.0 or higher; rest in bed or reclining chair. 

Evening temperature / 99 . 5 ; only short walk on the following day. 

at 7 p.m. \ 100.0 and above; complete rest during following day. 

Hill climbing, or walking long distances, up to fifteen miles a day in 
afebrile cases without tachycardia may be permitted. The author has 
thus tested patients as to their ability to work, and was surprised to 
find often that they were rather invigorated by the exercise and they 
were then allowed to work for their support. Our patients are told 
to come to the office on foot, walking a mile or two, and if when they 
arrive the pulse and temperature are found normal, they are told to 
walk a longer distance the next day, etc. When this test shows that 
no harm is done by the exercises the patients are allowed to work, 
first under supervision, and later completely discharged with instruc- 
tions as to the signs of danger. 

Graduated Labor. — Practitioners among people in large cities are 
often impressed with the capacity for work of many consumptives 
amid unfavorable surroundings for years without visible harm. Among 
these cases there are many who are evidently active but not progres- 
sive: some are entirely quiescent. We must repeat that the extent 
of the lesion is less of an index as to the capacity for work than its 
activity as revealed by the constitutional symptoms, such as fever, 
tachycardia, dyspnea, etc. Paterson 2 developed his system of graduated 
labor after observing such cases in England. "It occurred to me," 
he says, "that if some consumptive persons under adverse circum- 
stances and without any medical guidance could act thus without 

1 Consumption in General Practice, London, 1912, p. 223. 

2 Sixth Internat, Cong. Tuberc, 1908, i, 886. 



EXERCISE , 571 

apparent injury, they ought, under ideal conditions and with the work 
carefully graduated in accordance with their physical state, to be able 
to undertake useful labor. Oh this assumption manual work should 
be of great advantage to patients undergoing treatment in a sanatorium, 
as at first it would do much to meet the objection that members 
of the working classes are liable to have their energy sapped, and 
to acquire lazy habits by such treatment; second, it would make them 
more resistant to the disease by improving their physical condition; 
and third, it would enable them by its effects upon their muscles to 
return to their work immediately after their discharge." 

With a view to developing the muscles of the upper limbs, which 
are supposed to have more direct influence on the expansion of the 
lungs, Paterson 1 is not satisfied with walking alone. When a patient 
is found to be able to walk two miles a day without aggravating his 
condition, he is given a basket in which to carry mold for spreading 
on the lawns, etc. No case of hemoptysis or of pyrexia occurred 
among these patients. When they have been on this grade with nothing 
but beneficial results for from three weeks to a month, they are 
given boys' spades with which to dig for five minutes, -followed by an 
interval of five minutes for a rest. After a few weeks, several of the 
patients on this work, who were doing well, were allowed to work as 
hard as possible with their small spades without any intervals of rest. 
As they had all improved on this labor, larger shovels were obtained, 
and it was found that these patients were able to use them without 
the occurrence of hemoptysis or of a rise in temperature. About this 
time many of the patients were feeling so well that it became neces- 
sary to restrain them from doing too much. 

Paterson worked out a schedule for graded work which brought 
excellent results. It was noted that many patients on their arrival 
are somewhat remarkable for a somewhat sullen and apathetic atti- 
tude, but as soon as their physical condition undergoes amelioration, 
all traces of gloom and depression leave them and they become lively, 
cheerful individuals. In many cases in which the improvement was 
not prompt, the effect of harder Work was tried and often a progressive 
improvement was noted at once. Paterson found that the danger 
signals are: a temperature of 99° F. or higher in men and 99.6° F. in 
women, loss of appetite and slight headache. As soon as these appear 
the patient is to be put to bed until the temperature goes down to 
normal. In my experience, a rapid pulse is of even more importance 
as an indication that exercises are deleterious. 

Inman, working with Wright's method of ascertaining the opsonic 
index in patients under this graded work system of Paterson, found 
that it was at some part of the day well above normal and he explains 
it as due to the stimulus supplied by the work, inducing artificial 
auto-inoculation; that the organism responds by the production of 

1 Sixth Internat. Cong. Tuberc, 1908, i, 901. 



572 THE REST CURE 

immune bodies. In fact, whenever excessive auto-inoculation takes 
place harm is done. This, he points cut, must be readily recognized 
clinically if harm is to be avoided. "A patient doing well on the 
grade of work prescribed for him and with no abnormality of tem- 
perature suddenly complains of feeling tired, of loss of appetite and 
of headache; and the temperature chart registers an elevation to 
99° or 100° F. These are precisely the symptoms which are found 
during the negative phase after excessive dose of bacterial vaccine." 

Paterson is guided in his conduct of a case by the thermometer, 
and whenever the temperature registers 99° and over in men and 99.6° 
in women (by mouth), the patient is kept strictly in bed. AYhen 
work has been assigned, the temperature is watched, and as long as 
it is not increased by the exertion, the work is increased in d uration 
and intensity. Even afebrile patients who are of poor general condi- 
tion are not allowed to work, but kept at perfect rest, excepting that 
they are allowed to walk to and from the dining hall for their meals. 

It is thus evident that there is little new in this system of exercises 
and work. Physicians have always allowed their afebrile patients who 
are of good general condition and not easily fatigued to work and 
warned them to stop as soon as symptoms of toxemia, such as a 
tired feeling, weakness, debility, drowsiness, make their appearance. 
Intelligent patients have been given thermometers to guide them. 

Paterson' s method has, however, done a great deal for institutional 
patients by drawing attention to the importance of exercises and work 
in attempts at prevention of indolence which, in many cases, remains 
as a reminder of the disease and the institutional life to which they 
had been subjected. 

Outdoor Games. — Afebrile patients without tachycardia are to be 
encouraged to do some exercise in the open air, otherwise they are 
likely to brood over their troubles, and in some cases even harmed 
by obesity. Walking exercises alone are often insufficient to keep the 
average patient busy, and outdoor games are often good to help him 
pass this time pleasantly and to benefit the muscles, the appetite, and 
the metabolism. 

In advising a patient as to outdoor games we must always consider 
his life, habits, and customs before he took sick. Those who indulged 
in sports may be permitted to resume their favorite games, provided 
they do not raise the temperature or produce breathlessness. This 
at once excludes certain games. "All violent sports should be 
avoided," says Lawrason Brown, "Golf (without the full swing), 
croquet, fishing and hunting (not entailing too much exercise), gentle 
bicycle riding (on the level), rowing or paddling, skating (for those 
proficient), skiing, snow shoeing, swimming (in great moderation), 
and horseback riding may be indulged in with moderation when the 
disease has been arrested." 

It seems to me that of the outdoor games, golf is the best for patients 
who have just recovered from phthisis. Cricket, football, and athletic 



EXERCISE 573 

sports in general produce more or less dyspnea, while golf makes less 
violent demands on its votaries and is usually played in open, breezy 
places. 

Indoor Games. — The tuberculous patient is to be allowed some 
games for his amusement even when he is kept indoors, excepting when 
the temperature is above 100° F. and he is kept in bed during the 
whole day. I believe it is wrong to interfere with them when they 
play cards, checkers, and chess, as is often done in public sanatoriums, 
on the assumption that the excitement is liable to raise the temperature, 
provoke hemoptysis, etc. 'While it cannot be said that these games 
immunize the patients against such accidents, I have never seen such 
results follow when they are allowed to have some amusement during 
the long, lonesome days and weeks in the institution. 

Patients treated at home are not to be allowed to go to theatres, 
or other indoor and badly ventilated places of amusement so long as 
thev have fever. 



CHAPTER XXXV. 
OPEX-AIR TREATMENT. 

Most writers state that Brehmer was the first to demonstrate, in 
1859 in his sanatorium, the great value of the open-air method of treat- 
ment of tuberculosis. But it is a fact that he had many precursors. 
In 1840 George Bodington, a country doctor in the village of Erding- 
ton, published an Essay on the Treatment and Cure of Pulmonary 
Tuberculosis, in which he vigorously protested against the close con- 
finement of consumptives for fear of the evil influences of cold, fresh 
air, "forcing them to breathe over and over again the same foul air 
contaminated with diseased effluvia of their own persons." Arguing 
against the value of antimony, calomel, and bleeding, which were in 
vogue in those days, he urged the free administration of nutritious 
food and stimulants with plenty of exercise in pure and, if possible, 
dry, "frosty" air. In short, his great specific in phthisis was dry, 
cold air which, he said, had a most powerful influence in "healing and 
closing of cavities and ulcers of the lungs." 

Needless to say, he was severely handled by his contemporaries and 
so discouraged that he had to give up his method of treatment, con- 
verting his "sanatorium" into an insane asylum. Brehmer in Ger- 
many and Trudeau in the United States later took up work along the 
lines of Bodington and met with no small amount of opposition and 
ridicule from the contemporary leaders of the profession and the laity. 

At present the gospel of fresh air needs no evangelists to bring it 
home to most sufferers from phthisis; it is the acknowledged corner- 
stone of phthisiotherapy. The only difference of opinion is where and 
how it can be applied most effectively. Some send their patients to 
certain regions where the climate is alleged to have a specific influence 
on the disease; others direct them to sanatoriums where they may 
benefit by both the climatic advantages and certain therapeutic 
methods which are the hobby of the presiding genius. Many are con- 
vinced that similar advantages may be obtained at the home of the 
average patient. 

Where Open-air Treatment May be Obtained. — The open-air treat- 
ment consists in inducing the patient to live permanently in pure, 
fresh air, preferably outdoors or, when he must stay indoors, the air in 
the room is to be renewed constantly. There is no question but that 
this is best obtained in the country or in a special institution. But 
most patients cannot afford to leave the city for an indefinite period 
nor are there a sufficient number of institutions in any country to 



OPEN-AIR VS. CLIMATIC TREATMENT 575 

accommodate all active tuberculous patients with places for as long 
as the disease lasts. In fact, if all the patients were to decide that 
they want to submit to hospitalization for therapeutic or prophylactic 
purposes, it would be found that only a small fraction of the eligible 
could be accommodated. 

Says Edward Cummings: 1 "Personally I cannot see the need of 
banishing the tuberculous patient from his comfortable chamber to a 
shack in the back yard, or a woodshed, or a tent house in the dusty 
desert. One does not always have to go across the continent to get 
fresh air, not even out in the yard. . . . The ordinary bedroom 
for most persons is well enough." My own observations in large 
modern cities like Xew York, Boston, Chicago, St. Louis, Philadelphia, 
London, Manchester, etc., have convinced me that results can be, 
and are, obtained which compare favorably with climatic and institu- 
tional treatment. Of course, in the congested districts and slums, 
the overcrowded tenements are even less suitable for consumptives 
than they are for human habitation in general. But there are dis- 
tricts in every city which can be utilized for the purpose of housing 
consumptives and the results attained will not be behind those 
attained after sending patients far away from their homes at great 
expense and often hardship. Dr. Thomas Spees Carrington has done 
a great deal in popularizing suitable methods of open-air treatment 
for consumptives in cities. 

The suburbs around cities are suitable for families in which there 
are tuberculous members and the expense involved in moving them to 
these parts is comparatively trifling; in fact, the rent is often lower, 
and they need not lose their jobs or break up their business. The 
social and economic aspects of tuberculosis, which are but rarely con- 
sidered in this connection, assume a different aspect when the patient 
must not be sent far away from home or from the place of employ- 
ment of those he depends on. 

Open-air vs. Climatic Treatment. — These two methods must be 
kept distinctly apart. Experience has taught that there is no climate 
on the habitable globe in which consumption does not occur, or where 
a patient sick with the disease will surely recover, even when sent 
thither in the very incipient stage of the ailment. In the climatic 
resorts which have become popular — and it is a fact that the popular- 
ity of a region is by no means an index of its therapeutic efficacy — the 
patient must subject himself to a certain discipline, if he expects results. 
Irrational mode of life in the mountains or at the sea coast will aggra- 
vate the condition of a consumptive to the same extent as it will in the 
city. A healthful mode of life in any place will, and does, improve the 
condition of the average consumptive, no matter where he is. 

The treatment of tuberculosis in certain climatic regions, as we shall 
see later on, has its indications and contra-indications, while home 

1 Journal of Outdoor Life, 1912, ix, 257. 



576 OPEN-AIR TREATMENT 

treatment has certain advantages in this regard. It can be applied 
successfully in the treatment of nearly all cases, in all forms of phthisis, 
and in all its stages; striking results are obtained in patients with 
limited means as well as in those who are well-to-do; in febrile and 
afebrile cases; in hemorrhagic and cachetic cases; in those with or 
without gastric derangements. In short, in all cases of tuberculosis, 
in all its forms, in all stages of the disease, during any season of the 
year in almost any climate, except the arid. 

To be successful, it must be applied rigorously, methodically, and 
properly regulated by the physician. This is no more than institutional 
treatment depends on, excepting that the former is cheaper for the 
community which is charged with caring for its consumptives, and 
more attractive to many who have sufficient material means at their 
command. 

Dangers of Stagnant Air. — Our conception of the beneficial effects 
of indoor life has undergone radical changes during recent years. The 
reasons why the stagnant air in a room occupied by human beings 
is harmful are not clear. Recent investigations by Leonard Hill, 
Haldane, Benedict, Fliigge, C. E. A. Winslow, and others, have shown 
that it is not the excess of carbon dioxide or the decrease in the 
proportion of oxygen which renders the stagnant air harmful. The 
most deteriorated air in a badly ventilated room never shows on 
analysis as much as 1 per cent, of carbon dioxide, while in famous 
health resorts at high altitude there is a far greater deficiency of 
oxygen than can ever be found in the worst ventilated room. The 
specific organic poisons of human origin, the morbific anthropotoxins, 
of which some have spoken, have never been isolated. 

As Winslow 1 points out, recent studies indicate beyond any reason- 
able doubt that the more obvious effects experienced in a badly ven- 
tilated room are due to the heat and moisture produced by the bodies 
of the occupants, rather than to the carbon dioxide or other substances 
given off in the breath. Two fundamental experiments have been 
repeated again and again which would suffice to demonstrate, as F. 
S. Lee has so well expressed it, that the problem of ventilation is not 
chemical but physical — not respiratory, but cutaneous. These are: 
First, that subjects immured in close chambers and exposed to heat 
as well as the chemical products formed therein are not at all relieved 
by breathing pure outdoor air through a tube; and second, that 
they are completely relieved by keeping the chamber artificially cool 
without changing the air at all, and are relieved to a considerable 
extent by the mere cooling effects of an electric fan. 

Investigations made by the New York State Commission on 
Ventilation have shown that the temperature and the pulse-rate of 
an individual are markedly increased by even a slight increase in the 
room temperature; they also confirm Leonard Hill's observations that 

1 Science, N. S., 1915, xli, 625. 



TECHNIC OF TREATMENT 577 

overheated rooms enhance the susceptibility to respiratory diseases 
owing to changes in the mucous membrane which follow exposure to 
hot and dry air, and the resistance of animals to artificial infection is 
very definitely lowered by chill following exposure to a hot atmosphere. 

In connection with tuberculosis, in which the appetite is of such 
great importance, it is of interest that stagnant air reduces the 
desire for food perceptibly. In two series of experiments made by 
the above-mentioned Commission, standard luncheons were served to 
the subjects in the experimental chambers and the amount on their 
plates weighed. In one series the subjects consumed on the stagnant 
days an average of 1151 calories and on the fresh-air days an average 
of 1308 calories, an increase of 13 per cent. In a second series during 
colder w T eather, the average consumption was larger, 1492 calories 
for the stagnant and 1620 calories for the fresh-air days. 

We have here an explanation for the utility of fresh air in the treat- 
ment of tuberculosis. Stagnant air is bad primarily because of its high 
temperature and lack of cooling air movement, sometimes combined 
with high humidity. In fact, a lack of humidity, as Phelps has pointed 
out, makes hot air feel cooler and cold air feel warmer. It is very 
important that the air in a living room should not be dry, as it is in 
most of our artificially heated rooms during the winter. W. Freuden- 
thal 1 has shown the dangers of dry air in a recent study of the subject. 
Living in stagnant air the patient feels uncomfortable, inert and 
listless, and above all, loses his appetite for food, which is very essential 
in the treatment of phthisis. The open-air treatment seeks to remove 
the drawbacks of indoor life amid stagnant air. No doubt it is attained 
best in a good sanatorium, but it may be just as w T ell attained at home 
within the city lines in most houses. 

Technic of Treatment. — If the patient lives in a capacious home, or 
in one in which he may have a fair-sized, well-lighted, and ventilated 
room to himself, in a district or street which is not overcrowded, he 
may remain where he is. But in case he lives in the slum district of 
a large city, in a dingy and overcrowded tenement, he must move to 
better quarters which are available in every city. If his occupation, 
or that of those he depends on, is not in the way, it is even better that 
he move to the outskirts of the city, or to a suburb where certain 
advantages may be obtained which are not available or feasible in the 
city. 

A few words should be said about the various shacks, tents, special 
window tents, etc., which have been contrived for the city dweller 
with a view of giving him an opportunity to live outdoors, or in a well- 
ventilated room. Most of them are not feasible. They cannot be 
used in the thickly inhabited parts of cities; the tents or shacks can- 
not be placed in the back yards, on the roofs, etc., without attracting 
the curious, or even exposing the patient to eviction because of the 

1 New York Med. Jour., 1914, xcix, 1. 
37 



578 OPEN-AIR TREATMENT 

resentment of the neighbors. I have seen a few patients in New York 
City who have made use of these contrivances, but they were rare 
exceptions, and they lived in private dwellings in the outskirts of the city. 

But the average bedroom, excepting in the dingy tenements, is 
sufficient for our purposes. If the patient is allowed to remove the 
window sashes, both the upper and the lower, as Cummings suggested, 
he may convert it into open-air sleeping quarters. The patient's 
room should be large; one with a capacity of 3000 to 3500 cubic feet 
of air is best. But it must always be remembered that cubic space is 
of little value per se unless it is provided icith efficient means of ventilation. 

In modern apartments, rooms with windows opening into air shafts 
or narrow courts are not good for tuberculous patients; they should 
have rooms with windows opening into the street or a spacious court- 
yard. In apartment houses with elevators the top floor is the best, 
the higher the building the better. But in houses without elevators 
the advantages of the pure air in the upper stories are often negatived 
by the exertion necessary in stair climbing by walking patients; but 
the ground floor should be avoided . It should also be seen that trees 
do not obstruct the entry of air and light to the room and favor exces- 
sive humidity. The windows of the room must be located so that the 
sun's rays enter them for at least part of the day and penetrate at least 
ten feet into the room. 

The walls of the room should be painted, not papered. All unneces- 
sary curtains and hangings should be discarded, leaving nothing but 
roller shades on the windows. Carpets are obviously bad, but some 
rugs should be left on the floor. Bare floors are apt to discourage the 
patient as well as those around him. The rugs can be taken out at 
frequent intervals, aired, and disinfected. The floor should be waxed 
or painted, so as to be easily cleaned. Steam or hot-water heating is 
best; gas heating is to be avoided because it consumes oxygen from 
the air. 

Afebrile patients who are allowed outdoor exercises should remain 
in the room very little during the day. In the city they are to leave 
their rooms soon after breakfast and go to some neighboring park where 
they are to spend the greater part of the day. In the outskirts of the 
city or in the suburbs there may be sufficient space around the house, 
as well as porches, balconies, etc., on which they may exercise and 
rest comfortably, reading or doing some light work under careful 
supervision of the physician. Intelligent patients may be given 
thermometers with directions to guide them as to the effects of exercise 
or work. 

The season of the year has little effect on the outdoor life. The 
patient is to spend the greater part of the day outdoors during the 
winter as well as during the summer. Only intense cold, or sun rays, 
rain, or strong winds are to be avoided by seeking shelter. Excepting 
during blizzards, snow is rather invigorating to the average patient 
of this class. 



TECHNIC OF TREATMENT 579 

Sleeping Porches. — Those living in the outskirts of the city or the 
suburbs may have tents in which they sleep during the night and seek 
shelter during inclemencies of the weather. But the usual tent is 
rather stuffy and damp for a tuberculous patient. There are made 
at present tent houses, or canvas bungalows, which are excellent 
because of the comforts they afford and the good ventilation that may 
be had within them. 

It is, however, best that the patient remain the greater part of the 
day on the porch and in most cases he may sleep in a bed placed on 
the porch. During the day, in case perfect rest is to be enjoined, he 
may remain on some form of reclining chair of which there are at present 
manv on the market, such as the Adirondack Recliner, the Kalamazoo 




Fig. 89.— A knitted helmet for protecting head, neck, and shoulders. (T. S. Carrington.) 

Chair, the common hammock chair, the willow long chair, etc. During 
the cold winter he may also remain on the porch on one of these 
chairs during the day, and in a bed during the night. "The whole 
problem is one of sufficient bedclothes and the use of some sort of 
hood or head covering (Fig. 89); in short, to dress especially for 
sleeping out." As Cummings suggests, "by putting on a suit of under- 
wear, a flannel shirt, pajamas of outing flannel, and a hood of flannel 
or eiderdown, and furnishing the bed with plenty of light weight but 
warm blankets and comfortables one can sleep with a continuous flood 
of fresh air in severe weather with perfect comfort and safety." 

It is self-evident that sleeping porches are only feasible in rural 
districts, and not in large cities, excepting in their outskirts. But it is 
always important to remember that the proper construction of a sleep- 



580 



OPEN-AIR TREATMENT 



ing porch is not a simple matter. A. Morgan MacWhinnie 1 investi- 
gated 100 sleeping porches in the Northwest and found the follow- 
ing conditions: In 96 cases the sides of the sleeping balcony were 
partially protected from the wind and rain by a tarpaulin or some 
other material. Two had no -protection whatever, and one was 
inclosed with glass windows which could be thrown open horizontally 
at night on retiring. This was the only one that could be closed in 



OPEN 



^\ SLEEPING y^ 
\ PORCH s^ 


\ 


.__!____ 




BED ROOM 

SCALE %"=V ^^ 



Fig. 



90. — Porch exposed on three sides: no provision for keeping the bed warm 
during the day. (MacWhinnie.) 



the daytime, and had hot-water radiators connecting with the boiler 
in the cellar that kept the bed and its covering as warm all day as the 
rest of the house. In 98 cases the bed, mattresses, linen, and covers 
were exposed all day to the dampness of the atmosphere. I found 
similar conditions in most of the sleeping porches in the East. 
The warming of the bedding and coverings and keeping them dry are 



1 New York Med. Jour., 1914, xcix, 780. 



TECH NIC OF TREATMENT 



581 



elements which are very often neglected in open-air treatment and 
it is not surprising that most patients do not want to sleep outdoors 
on cold and moist days. MacWhinnie suggested sleeping porches 
which have none of these disadvantages; they are so arranged as to 
be completely protected from the weather. He urges that the doors 
should be large so that the bed can be kept in the heated room during 
the entire day and bedding remains warm and dry. When ready for 
the night, it should be wheeled onto the sleeping porch, thus obviating 
disadvantageous conditions mentioned above. 



OPEN WEST 




Fig. 91. — Ideal sleeping porch. When the bed is fully extended on the porch, the 
footboard closes the room from the outside air; when bed is in warm room, headboard 
closes opening to sleeping porch. (MacWhinnie.) 



Figs. 90 and 91 show the plan of a sleeping porch, designed and 
constructed by Dr. D. C. Hall. An opening is made in the wall large 
enough for the bed to roll through onto the porch. The head and 
foot boards are so constructed that the opening in the wall is entirely 
closed when the bed is at full length on the porch or in the room. 
The room is thus kept warm for dressing in the morning. The bed 
is supported by four large roller-bearing wheels, one hand of a child 
sufficing to move it out or in. Grips are so arranged that the bed can 
be drawn out or in, while the occupant is in the reclining position. 



582 OPEN-AIR TREATMENT 

Open-air Treatment of Febrile Patients. — The afebrile patient may 
indulge in driving, automobiling, or sleighing during the winter, but 
always within the limits set by the physician. 

He should discard many of the pleasures of healthy people, even 
when he thinks he is well; he should not visit theatres, balls, crowded 
restaurants, etc., where large numbers of persons congregate and 
contaminate the air. Many a patient who has been doing well, and 
was on the road to recovery, has suffered a relapse or a complication, 
after attending a function at which a large number of persons got 
together in a confined space. 

With febrile cases things are not so simple. They must remain 
in bed as long as the fever lasts, excepting under circumstances 
which are discussed elsewhere. In the city the bed can only be kept 
within the room and for this reason, as well as for others, it must be 
placed near the window, so that not only pure, fresh air may be avail- 
able at all times, but also because the patient is usually encouraged 
looking out at the . living world. In the suburbs the bed may be 
placed on the porch during the day, and under certain circumstances 
it may remain there all the time. When feasible, a proper tent or porch 
is even better. Placing tents on roofs of houses in the city, or modifying 
fire escapes so that the patient may be kept on them in the open air, 
is not feasible. No patient wishes to expose himself to the curious 
gaze and commiseration of the other inhabitants of the house, as was 
already mentioned. 

The good effects of the open-air treatment are very striking in febrile 
cases. The general condition of the patient improves, a feeling of 
well-being ensues, replacing the despondency into which he was 
sinking. His strength returns. The anorexia and indigestion which 
sapped his strength disappear, or are ameliorated, and he eats with a 
better appetite. The painful cough often disappears within a few 
days and nights with open windows or on the porch. This is at times 
the most salutary phenomenon; sometimes when sedatives have failed 
to control the cough, outdoor life works in this direction and the effect 
on the morale of the patient is marvellous. 

We often have patients who, in mortal fear of "colds," decline to 
carry out the open-air treatment; their relatives and friends discour- 
age them yet more. But several days' experience along the line just 
described convinces the average patient. At the Montefiore Hospital, 
where the patients come from the tenement districts of New York 
City, and have always feared open windows, they soon find out the 
advantages of fresh air and would strongly resent any attempts at 
closing the windows. It is often necessary to control the "fresh-air 
fiends/' when conditions arise which necessitate their remaining 
indoors for some time. 

The superstitious fear for colds and draughts is one of the greatest 
drawbacks in phthisiotherapy. The patients are apt to ascribe all 
their troubles to colds. After passing through an acute exacerbation 



TECHNIC OF TREATMENT 583 

of the disease, which they usually ascribe to a cold; or getting some 
pain or ache in the chest, or hoarseness due to laryngeal complication, 
etc., they begin to fear exposure. This is to be discouraged. The 
patient is to be told clearly and distinctly that his troubles are not 
due to fresh air, but to the lack of it, and that a cure can only be 
attained by living outdoors. 

During the night the open-air treatment is just as simple as during 
the day. It consists in one simple principle— open windows. They 
must be opened completely; the upper half must be completely 
lowered and the opening should not be obstructed by any shade or 
curtain. Patients who have not slept in a well-ventilated room — the 
fact that they are phthisical shows that they have not — and are not 
habituated to cold air during the night, rebel when told to open their 
windows widely during winter nights, but a trial of a few nights con- 
vinces most of the sceptics. 

With obstinate patients we may begin by lowering the windows one- 
third; after a few nights the opening is increased to one-half, etc., 
so that within a week or two the patient finds out that sleeping with 
a free current of air invigorates him and he will not tolerate their 
closure. 

Half -measures, such as opening the windows in adjoining rooms, 
etc., are not to be tolerated. The patient should be impressed with the 
fact that it is not only fresh air we are looking for, but a free circulation 
of it and this can only be attained by keeping the windows open in 
the room he inhabits. 

As a rule, there is no necessity for heating the sleeping room for the 
night during the greater part of the winter. Warm sleeping rooms are 
badly ventilated. Only during the very cold days is there a necessity 
for heat, but the windows must remain open. Careful measurement 
has shown that the temperature within the room is always above 
that outside, and the humidity is lower. A sufficient number of 
blankets and plenty of flannel underwear, used according to the 
temperature, will keep any patient warm. The fear entertained by 
many patients that exposure of a limb in a cold room may be harmful 
is not supported by facts observed in daily practice. The human 
being keeps its limbs instinctively covered when sleeping in a cold 
room. Moreover, insomnia is sure to occur if he is not well covered. 
It is also a fact that persons lying in bed well covered feel quite warm 
in a room so cold that those around find it difficult to bear, as is the 
experience of nurses attending to outdoor patients. 

It is self-understood that very few patients will at once begin the 
treatment by undressing in a cold room during the winter and going to 
bed and again dressing in the morning in a cold room. For this reason 
it is much easier to institute the treatment during the summer. But 
in winter we may begin by warming the room an hour or so before the 
patient is expected to retire, and again before he rises in the morning. 
But in time many patients discover that all this is unnecessary and they 



584 OPEN-AIR TREATMENT 

undress and dress in a cold room without a murmur. In many cases 
the patients prefer to have an adjoining room for this purpose. 

Wind, rain, and snow are not sufficient reason for closing the win- 
dows of the sleeping room of the patient. This must be insisted upon 
and the patient should be convincingly told that it is the fresh, circulat- 
ing air which replaces his expired air and cools his body that keeps up 
his vitality. Even during complications of phthisis the windows are 
not to be closed in the vast majority of cases; most of these are pre- 
vented or cured by fresh, cold air. 

In moderate climates consumptives feel better during the winter, 
as was already shown when discussing hemoptysis, emaciation, etc. 
It is the universal experience that when the summer heat is accom- 
panied by excessive humidity, tuberculous patients suffer from anorexia, 
insomnia, general weakness, etc., and they often lose the greater part 
of what they gained during the cold winter. For this reason I 
insist that all patients under home treatment should leave at least 
for the two months of July and August for the mountains. It is also 
well that during warm days an electric fan should be installed in the 
rooms inhabited by consumptives for reasons already made clear. 

Results Attained by Open-air Treatment. — The results attained by 
the open-air treatment depend on many conditions, notably the acute- 
ness and the stage of the disease. In acute, progressive cases we cannot 
expect much more than from any other method of treatment, except- 
ing perhaps more comfort to the patient than would be the case if 
he were kept indoors. The ultimate prognosis is gloomy at all events. 
In fact, if these patients insist that they cannot bear the cold, it is 
of no use arguing with them; it is best to let them have their own 
way during their last earthly days. In subacute cases the process is 
at times arrested and the disease then pursues the course of chronic 
phthisis. 

The good effects of the open-air treatment are best seen in the 
average case of incipient chronic phthisis which begins with moderate 
fever, nightsweats, anorexia, cough, etc. In advanced cases of the 
disease, when the patient is emaciated and apparently hopeless, several 
days of life in the open air often transform a despondent individual 
into one who shows his confidence in ultimate recovery very clearly. 
He gains in courage and is imbued with a desire for recovery; his fever 
declines, the nightsweats disappear, the cough and expectoration 
diminish, and he becomes hopeful in general. 

In the far-advanced stages of the disease the open-air treatment 
may only render the last days of life somewhat more bearable, contrib- 
ute to the false optimism which is often seen in these patients, and 
accentuate the euphoria which has been considered characteristic of 
the disease. But it is undoubtedly curative in the vast majority of 
incipient cases. The entire aspect of the patient is often transformed 
within a week or two, and the improvement is usually progressive. 
A good appetite with proper assimilation and digestion of the food, dis- 



CONTRA-INDICATIONS TO OPEN-AIR TREATMENT 585 

appearance of the fever, nightsweats, insomnia, and amelioration of the 
cough, are the rule in these cases. Often it will be noted that fever, 
which resisted all other treatment for months, disappears after several 
days of life with open windows during day and night. Many patients 
learn it by experience and cannot be induced to close the windows. 
They have found that with open windows they sleep better and feel 
refreshed in the morning, while closed windows induce cough, night- 
sweats, insomnia, listlessness, etc. 

Contra-indications.— It must be emphasized that there are but few 
contra-indications to the open-air treatment. Even hemoptysis, how- 
ever severe, should not induce us to close the windows of the room 
inhabited by a tuberculous patient. Nor should they be closed during 
any season, as was already mentioned. Only during the summer, 
when the external air is often hot and humid, and even open windows 
are not effective in producing a free circulation of the air within the 
room, this method is often futile. An electric fan may improve con- 
ditions somewhat, but it is best that patients who can afford it should 
leave the city for a milder or colder region. 

There is a small number of patients who do not bear the open-air 
treatment very well during the winter months; in fact, in some it is 
distinctly harmful, and if an attempt is made to apply it, it must be 
done with great care and circumspection. Patients who suffer from 
diffuse bronchitis in addition to phthisis do not bear cold air very 
well and so-called "rheumatic pains" in the joints are often aggra- 
vated by sleeping in a cold room. Cold air is also bad for consumptives 
who suffer from organic heart disease — dyspnea and the cough are 
decidedly provoked by winds, draughts, and cold air in general. Those 
suffering from profound anemia at times cannot be kept warm by any 
means in a cold room. Some nervous patients who have obstinately 
made up their minds that the cold is harmful are also bad material 
for this mode of treatment. The same is true of old persons with bad 
peripheral circulation and extremely cachectic patients — they cannot 
be kept comfortable in cold rooms during winter nights. 

In all these cases it is necessary to heat the room, but the windows 
should under no conditions be closed completely. On the other hand, 
when some complication ensues, such as influenza, pleurisy, pneumonia, 
etc., there is no necessity for closing the windows. These conditions 
are also benefited by fresh, cold air. 



CHAPTER XXXVI. 
CLIMATIC TREATMENT. 

We have seen that the vast majority of tuberculous patients are 
amenable to home treatment; if they are to recover at all, they can 
accomplish it without leaving their home surroundings. The autopsy 
findings showing that many persons have healed tuberculous lesions 
in the lungs and pleura, although they have never undergone a course 
of institutional or climatic treatment, prove clearly that tuberculosis 
is curable in all climates. But there are undoubtedly indications for 
certain forms of climatic treatment in tuberculosis, though they are 
not as imperative nor as necessary for the average case as the laity 
and part of the profession believe. In this chapter we shall attempt 
to review the indications and point out the limitations of climatic 
treatment. 

Climatic treatment of tuberculosis is probably older than any other 
method which has survived, the recent advent of scientific medicine. 
The ancient Greek and Roman, as well as the medieval Arabic physi- 
cians were great believers in the efficacy of certain climates in the 
control and treatment of phthisis. The first thought that enters the 
mind of the average modern physician after diagnosticating a case of 
tuberculosis is, "Where should I send the patient?" If the physician 
is negligent in this regard, the patient will surely ask him, "Must I 
leave the city?" 

It is, however, a fact agreed to by all entitled to an opinion that 
recent studies of the effects of various climates on the incidence and 
the course of phthisis have not resulted in discovering a region on the 
habitable globe which can be relied on to cure or improve all incipient 
or a substantial proportion of advanced cases of the disease. When- 
ever geographical, topographical, meteorological, and clinical data are 
correlated with demographic data for a given locality, and conclusions 
drawn that a very high percentage of cases recover when sent there, 
there are at once shown other facts which prove conclusively that 
under climatic conditions diametrically opposed to these, the propor- 
tion of recoveries is about the same. For these reasons many physi- 
cians have gone to the opposite extreme and claim that climate need 
not at all be considered as a therapeutic agent in the control and cure 
of phthisis. 

Economic Aspects of Climatic Treatment. — Other reasons militating 
against the extensive utilization of certain climates may be mentioned. 
Bearing in mind that the bulk of consumptives are recruited from the 



COST OF CLIMATIC TREATMENT 587 

poorer strata of society and that even those who had been self-sup- 
porting before they were attacked by the disease often become depend- 
ent soon after that event, it is evident that the economic factor is 
to be given great weight in this connection. Indeed, climatic treat- 
ment is as expensive as institutional treatment; it is even more 
beyond the reach of most patients because modern municipalities 
provide, as a rule, institutions for the tuberculous, but hardly any 
supply funds with which patients may go to distant parts of the country 
and support themselves for a considerable time. 

This economic aspect of climatic treatment is too often disregarded 
by physicians who tell their "patients, irrespective of their financial 
condition, to go to distant regions. Those who cannot raise the funds 
and must stay at home become despondent and the prognosis is often 
aggravated as a result of it. Some of them go with meagre funds to 
Colorado, Arizona, California, etc., and the result is even more dis- 
astrous. 

Cost of Climatic Treatment.— Thompson Fraser, 1 who has made a 
study of this problem in Asheville, N. C, and reported his observations 
in the Public Health Reports, shows that it must always be borne in 
mind that there is a clear relation between income and recovery in 
tuberculosis. When leaving for some climatic region, the patient 
must be prepared to provide himself with the proper requisites. If 
he lacks funds he should not undertake a trip which not only exhausts 
his resources, but does him no good; he should rather stay at home. 
He points out that at Asheville, and this holds good for nearly every 
other climatic resort in this country, the expense is about as follows: 

The cost of room and board varies within wide limits. From his 
observations at Asheville, board of fair quality with room costs from 
$10 to $12 a week at the houses which are licensed to take tuberculous 
patients. The price depends to some extent on the location of the 
rooms, the more desirable ones costing more, while less desirable rooms 
may be had for $8. The "extras," Fraser points out, amount to 
almost as much as the cost of the room and board, including, as they 
do, additional food, milk, eggs, reclining chair, physicians' fees, medi- 
cines, thermometers, blankets for cold weather, laundry, and every- 
thing that comes under the item of "incidentals." 

Fraser's conclusions are that the cost to the patient for a period 
of ten months, or forty-three weeks, at $8, $10, $12 a week would be 
$344, $430, $516, respectively, not including the extras just men- 
tioned. A minimum of $700, therefore, exclusive of car fare, would 
be a more just estimate of the expense for the rather arbitrary period 
of ten months. If the patient is accompanied by some member of the 
family, it may be decided to keep house instead of to board, but this 
will not prove more economical in most cases. 

The estimate for room, board, and treatment for a period of ten 

1 Public Health Reports ..September 18, 1914, xxix. 



588 CLIMATIC TREATMENT 

months applies especially to those cases which can be benefited by a 
comparatively brief stay. If the disease has made greater inroads, 
and a longer stay is necessary to produce results, the cost of extras 
and perhaps of nursing may be prohibitive to the average consumptive 
and it is wiser to remain at home where suitable food, care, and com- 
forts will more than outweigh the benefits of climatic factors if 
unassisted by these essentials. 

Climatic treatment is thus a luxury available for the chosen few, 
while the vast majority of sufferers from tuberculosis must perforce 
remain in their homes for treatment. 

Effects of Change of Environment. — Looking with a sane and 
unbiased view on the problems of climatic treatment of phthisis, we 
find that it is undoubtedly an important adjuvant to our efforts at 
curing our patients. Even physicians who practise in cities and have 
good results with home treatment are often impressed with the salu- 
tary effects of a change of surroundings. One has but to note the 
effects on a patient wiio has been kept at home for several months, 
and all available hygienic, dietetic, and therapeutic measures to control 
the disease have been taken, yet the patient has been going steadily 
downward. A change in surroundings is decided upon and he is sent 
out to the country, preferably a place the patient selects, provided 
there are no strong objections to it. It makes no difference whether 
the locality selected is at the sea coast or inland, in a forest or a desert, 
on a high altitude or the plains; it is immaterial whether the number 
of sunny days calculated by the weather man, or by the owmer of the 
resort in the neighborhood, is small or large, whether it is foggy or 
even frequently rainy — the results are often astonishing. After 
remaining there for a few months, the patient returns greatly improved, 
in some cases even apparently cured. These are the facts which every 
observing physician is bound to meet in his daily practice and cannot 
be controverted by statistics or opinions of famous clinicians. But it 
is clear that in such cases it is not the meteorological or topographical 
conditions which are altogether responsible for the good results attained 
by the change. 

Carefully analyzing the results obtained by patients under my 
observation, I have arrived at the conclusion that the complex phe- 
nomena grouped under the title "change of environment," or the 
psychic and biological response of the organism to a change in surround- 
ings, play here a greater role than the difference in the composition and 
density of the air or the number of sunny and foggy days. The change 
in environment acts as a new stimulus, reinvigorates, and calls forth 
the dormant vital forces of the patient. 

Suggestion is a factor in climatic treatment of tuberculosis which 
has not been given the credit it deserves. The patient has heard that 
a consumptive cannot recover in the city, and, when unable to leave 
for any reason for some place reputed to be efficacious in this direction, 
he becomes despondent. Many brood over it to an extent as to negative 



EFFECTS OF CHANGE OF ENVIRONMENT 589 

all other therapeutic measures. Once they are sent away, all potential 
and inherent vital forces are stimulated; despondency is replaced by 
a feeling of hopelessness, accompanied by an increase in the appetite, 
improved assimilation of food, diminution in the cough, etc. This is 
proven by the following facts which have come under our observation : 

Patients leave their homes where they have been under the tender care 
of relatives and have had good and properly prepared food, and go to the 
mountains or the sea coast where they are compelled to live in cheap 
boarding houses or hotels, in which the food given them is far inferior 
to that which they had been getting at home. Yet they thrive and gain 
in weight, while at home they had been wasting progressively. Others 
go to hotels and boarding houses which, for obvious reasons, allege in 
their advertisements that, the in reality much-coveted, consumptives 
are barred. In fear that when coughing the proprietor of the hostelry 
is liable to discover their ailment, the patients promptly cease cough- 
ing. In many cases the gain is only temporary and after the so-called 
acclimatization, the " climate wears out." Brown 1 says that it is rarely 
advisable for a patient to remain in any climate without change for 
more than eight or nine months. But the gain is immense in a large 
proportion of cases. The disease often takes a turn to the better, 
or the patient is carried over an acute exacerbation and given an 
opportunity to recover his inherent vital forces. 

This effect of a change of environment is often seen in patients, 
themselves natives or residents of agricultural districts, even high 
mountainous regions, who have become sick with tuberculosis, and 
coming to the city to consult a physician improve, in spite of the fact 
that climatic conditions are undoubtedly inferior. But there has been 
a change of environment. 

That it is not entirely the climate per se which is responsible in all 
cases which improve by a change, is acknowledged by most authori- 
ties on medical climatology. Henry Sewall 2 points out an antagonism 
between the vital effects immediately attendant on a change of climate 
and those, often totally different in character, which may develop 
during permanent residence. " In short, a change of scene, irrespective 
of the character of the environment, has often temporarily a myste- 
rious influence for good on the living organism. The first vital reactions 
to new climatic conditions involve especially the nervous system, the 
final effects are dependent on the modified metabolism of the individ- 
ual organs, and this may or may not be conducive to the efficiency of 
the body as a whole." Brown puts it pointedly when he says that 
without doubt many of the effects attributed to climate can be ascribed 
to change of climate. 

The writer has observed patients who left a favorable climate, where 
they have done badly, for an unfavorable one, where they soon improve 
wonderfully. Many immigrants who become tuberculous in New York 

1 Osier's Modern Medicine, i, 488. 

2 Klebs' Tuberculosis, p. 664. 



590 CLIMATIC TREATMENT 

City, try institutional treatment and fail to improve. A longing for 
their native land overtakes them, and they return home where they 
remain for some months and return to this country cured. We have 
observed numerous instances of this kind in New York. From personal 
observations, the writer can testify that the hygienic, sanitary, eco- 
nomic, and social conditions in southern Italy, Hungary, Russia, and 
Poland, where these patients go, are inferior to those in which they 
live in New York. Indeed, tuberculosis in those countries is more 
ravaging than here; is more often fatal. Nor are there sufficient 
accommodations for dependent consumptives. Still, many immigrant 
patients, who fail to get relief in the many excellent public sanato- 
riums in this country, in the mountainous regions of Colorado, Arizona, 
or the beautiful parts of Southern California, go to some large or small 
city in southern or eastern Europe .and, after remaining there for 
several months, return apparently cured and able to work. 

There is no doubt that in such cases it is not the climatic conditions 
that helped, but the confidence they placed in their native lands, in 
the home surroundings, in the caressing tenderness of loving relatives, 
etc., which was instrumental in awakening the reparative forces of the 
organism. 

There are other reasons for sending patients, who can afford to go, 
to some region with a favorable climate. It is very often difficult to 
enjoin complete rest and freedom from the worries and anxieties of 
every day life in the home of the patient. Nor can he be kept from the 
temptations of city life. These objects may be accomplished by remov- 
ing him from his home environment into some secluded country place. 
The patient is to be told that he will have to remain away from home 
for several months and he should not leave unless he has sufficient 
funds for the purpose. His relatives are to be warned against inform- 
ing the patient of any troubles at home. To this must be added the 
regular hours for meals, rest, exercise, etc., which are followed implic- 
itly in the country, but often disregarded in the city with its tempta- 
tions. I have had results which were astonishing with patients sent 
away in this manner. 

With some patients institutional treatment is best for these reasons, 
as will be shown later on, while with others the reverse is true. In 
fact, many patients are better off when sent out to roam freely in 
the country than when sent to closed institutions. 

Where to Send Patients. — Experience has shown that for the vast 
majority of cases of incipient and uncomplicated phthisis it makes little 
difference whether they go to a mountainous region or to lowland, to 
the sea coast or inland, to a moderate or cold region; the effect is 
practically the same, as long as they are taken away from their homes 
and placed under favorable surroundings, away from the troubles of 
home life. There is no climate which cures consumption, the many 
laudatory advertisements of institutions and railroad companies not- 
withstanding. The fact that nearly all successful sanatoriums, located 



MOUNTAIN CLIMATES 591 

as they have been in such a diversity of climatic environments, show 
practically the same proportion of cured, arrested, improved and last 
but always least, dead, proves conclusively that if the climatic con- 
ditions are a factor, they are of least importance. 

A careful perusal of Guy Hinsdale's prize essay on Atmospheric 
Air in Relation to Tuberculosis, which is one of the best books on the 
subject, and most impartial, because the author is not anxious to boost 
some region or institution, shows clearly that climate is of little thera- 
peutic importance in tuberculosis. He admits that good results are 
obtained in cloudy regions, as, for instance, in the Adirondacks, and 
at Rutland, Mass. He has no objection to sunshine, because the 
moral effects of bright sunny days, and plenty of them, are very great. 
As to the question of temperature and humidity, Hinsdale concludes 
that the majority of incipient cases do best in dry and cool places 
"not warm enough to be relaxing, but not so cold as to be repellent 
and restrict exercise and out-of-door life." The old ideas about 
equability of temperature, at least between the temperature of mid- 
day and midnight, are not of great importance; all mountainous sta- 
tions show great variations in this respect. Some variability tends to 
stimulate the vital activities, but in older people and those who are 
feeble, great variability is a disadvantage. Hinsdale denies that alti- 
tude per se has any great influence. It is of benefit mainly because it is 
incidentally associated with mountain life, with more sun, less moisture, 
and scattered population. One statement made by this author should 
be reprinted with heavy type in all discussions on the subject. "That 
a place is frequented by consumptives does not prove that it is a 
desirable place for them." 

Mountain Climates. — When a change has been decided upon, the 
first thought which enters the mind of the patient, as well as that of 
the physician, is whether a high altitude is best. High climates have 
been popular for centuries; even ancient physicians, who believed that 
phthisis is invariably fatal, sent their patients to the mountains when 
feasible. Most of the modern sanatoriums are located in regions of 
high altitude. 

We do not know why high climates are beneficial for consumptives. 
Various hypotheses have been formulated to explain it, but none have 
been proven. The purity of the air is beyond question; the absence 
of massed population assures freedom from air contamination. Humid- 
ity is also less frequent, though not so rare as some would lead us to 
believe, and many sanatoriums are located in regions which are noto- 
rious in this regard. The air is cool, even during the summer, especially 
in regions of 4000 feet or more above sea level. But the cold is not felt 
as acutely even during the winter owing to the greater diathermancy. 
The ozone, of which many writers of past generations spoke so much, 
has been found to be worthless. There is very little ozone, and even 
if there were more we do not know that it would do much good to the 
patients. 



592 CLIMATIC TREATMENT 

The diminished atmospheric pressure and rarified air have been con- 
sidered beneficial by increasing the mobility and expansibility of the 
thorax. It promotes deeper, fuller, and more frequent respiration. 
But how much of this is due to the outdoor life and whether outdoor 
life at lower altitudes has not a similar effect on consumptives, have 
never been satisfactorily investigated. 

The effects of high altitude on the hematopoietic organs and tissues 
have been investigated and some have found an increase in the amount 
of hemoglobin, others, a polycythemia, still others an increase in the 
number of leukocytes, etc. Webb and Williams 1 have found an 
increase in the lymphocyte, or mononuclear elements of the blood, as 
an effect of high altitude. Some authors, notably Bartel, Bergel, 
Marie, and Fliessinger, have seen in this increased lymphocytosis in 
tuberculosis a defensive attempt on the part of these blood cells, while 
others see in it a demonstration that the lymphocytes contain a lipo- 
lytic ferment which destroys the waxy coat of the tubercle bacillus. 
Minnie E. Staines, T. L. James, and Carolyn Rosenberg 2 confirmed 
these findings in Colorado. They found that at an elevation of 6000 
feet the larger lymphocytes are absolutely increased in the circulating 
blood by at least 20 or 30 per cent, in both man and monkeys. Webb, 
Gilbert, and Havens 3 found an increase in the blood platelets in tuber- 
culous human beings and monkeys, and that at high altitudes the 
increase is even more pronounced. But that these blood platelets 
contain or supply opsonins or that they play a role in the cure of 
tuberculosis has not been proved. On the whole, it appears that 
the hematologic studies of phthisical subjects are contradictory and 
it has been shown that the conflicting findings have been due in a 
great measure to errors in technic. It may be stated that the hypoth- 
eses promulgated by some authors have not been confirmed by facts 
observed by other investigators. 

Some have maintained that the proliferation of connective tissue 
in the lungs, the true reparative process in phthisis, is enhanced by 
a residence in the mountains. But von Muralt, who formulated this 
theory, has not given any substantial and convincing proof. 

Even the statistics tending to show that deaths due to tuberculosis 
are less frequent in mountainous than in other climates have not with- 
stood scientific tests. It appears that tuberculosis was rare in the 
Rockies, the Andes, etc., as long as the population was sparse, the 
inhabitants leading an outdoor life, etc. But since cities have been 
established at high altitudes and social conditions favoring the devel- 
opment of phthisis created, the disease is not infrequent among the 
indigenous population. The American Indians, when infected with 
tubercle, succumb to the disease despite residence in the mountains. 

It is thus clear that economic and social conditions play the same 
role in the cure of tuberculosis in the mountains as they do in the 

1 Tr. Nat. Assn. Study and Prevent. Tuberc, 1909, v, 231. 

2 Arch. Int. Med., 1914, xiv, 376. 3 Ibid., 1914, xiv, 743. 



MOUNTAIN CLIMATES 593 

plains or at the sea coast. On this point all authors are agreed. When 
a patient goes to a high climate, penniless, and starves there, he will 
succumb just as quickly as he does in the slums of the city. If he works 
in Phamix, Denver, etc., while the disease is active, he may breathe all 
the rarified air, expand his chest to an extreme degree, and still succumb 
just as quicklyas in the city. It is only those who can afford rest, good 
nourishment, and careful medical supervision who are benefited bv 
life in a high altitude, and most of these are also doing well in other 
climates. 

Indications for High Climates. — High climates are no panacea for 
tuberculosis; in some cases they are not an unmixed blessing. They 
have their indications and contra-indications. 

Patients in whom a positive diagnosis of active phthisis cannot be 
made but who nevertheless show symptoms and signs of the disease 
-—in other words, the socalled "suspects" — may be sent to the mowi- 
tains for a short or long stay on the principle that they need a rest anyway. 
But we must be careful and not suggest such a vacation to those 
with limited means. I have seen self-supporting artisans ruined, their 
children committed to asylums, while the father was sent away 
to the mountains without a positive diagnosis of tuberculosis. That 
they returned within a month or two reinvigorated and in excellent 
health was not sufficient to justify the sacrifice; the same result 
could have been obtained by less costly means. It is different with 
the well-to-do, who mostly court a vacation. 

A large number of neurotics, anemic and debilitated individuals 
who are in constant fear of tuberculosis, and in whom a diagnosis has 
been made by some physician, but careful examination fails to elicit 
any symptoms and signs pointing to a lesion in the lung, are nearly 
always benefited by a stay in the mountains. Phthisiophobia, which may 
be considered a distinct syndrome common in modern times, should 
be treated in the mountains when patients can afford the change. 
They may remain under the impression that they have been cured of 
tuberculosis, but this does not make any material difference so long 
as they are relieved. 

Many of these "suspects" and " phthisiophobiacs" may have been 
cases of abortive tuberculosis in which the physical signs were indefi- 
nite or absent. The rest in the mountains and the change of environ- 
ment undoubtedly contribute to their recovery. 

Incipient cases of tuberculosis with feiv constitutional symptoms 
gain considerably by a change for a mountainous climate. The appe- 
tite improves, the anemia vanishes, and they often gain in weight 
better than they would have in the city with its temptations. The 
patients are also freed from the troublesome solicitations of their 
relatives and friends which are often more a detriment than a help to 
recovery. 

Active phthisis in the moderately advanced stage which does not improve 
under home treatment for any reason may be sent to the mountains for a 
38 



594 CLIMATIC TREATMENT 

prolonged stay. It is at times surprising to see marked improvement 
manifesting itself soon after their arrival in the country. Fever is no 
contra-indication, provided it is not of the hectic or terminal variety, 
or due to some complication which may be aggravated in a high 
altitude. Occasionally a pleural effusion showing no tendency to absorp- 
tion will disappear after a stay in the mountains. F. L. Knight preferred 
patients of phlegmatic temperament to the nervous, with irritable 
heart, frequent pulse, and inability to resist cold. 

Of course, most tuberculous patients who can afford the expense 
should be sent to the country, preferably the mountains, during the 
hot and humid summer months. 

Contra-indications. — As was already stated, high climates are like 
a double-edged sword and may be harmful. As a general rule it may 
be said that hopeless cases, running an^acute course with hectic or high 
continuous fever, with a rapid extension of the process in the lungs, pro- 
found emaciation, edema of the extremities, etc., should not be sent, for 
obvious reasons. It is a great pity to send them travelling great dis- 
tances, which aggravates their already bad condition, to suffer or die 
among strangers. Their relatives are also to be considered. Upon 
hearing of the desperate condition of the patient on his arrival at his 
destination they may have to go to see him. 

Some of these progressive and apparently hopeless cases take a 
turn to the better with careful home treatment; the fever abates, the 
appetite improves, the strength begins to return. At this stage it 
may be well to send them away to the mountains where the improve- 
ment which began in the city is enhanced by the new surroundings. 
At any rate, they do not lose by the change and, when they can afford 
it, it may contribute greatly to their ultimate recovery. But they 
need experienced nurses to take care of them. 

Dyspnea is a strong contra-indication to a mountainous climate. 
It is often not considered and the results are disastrous. Consumptives 
with dyspnea due to pulmonary emphysema, asthma, and fibroid 
phthisis, all of which mean cardiac dilatation; or due to cardiac 
hypertrophy of a high grade, fatty degeneration of the heart muscle, 
nephritis, arteriosclerosis, etc., should not be sent to a high altitude. 
F. L. Knight objects to persons over fifty years of age. Tachycardia, 
when the pulse is much over 100 per minute, and not slowing down 
after a long rest, is also a strong contra-indication. 

Amyloid degeneration of visceral organs, advanced laryngeal, intestinal, 
and peritoneal tuberculosis are contra-indications. This is not because 
the climate is harmful, but the hopelessness of the case precludes 
sending the patient far away from home. Schroder, whose experience 
has been very large, warns against sending patients with signs of com- 
mencing cardiac weakness and with strongly accentuated neuroses to 
an altitude of over 1000 meters above sea level. 

In selecting patients for high altitude, we must not put very much 
weight on the climatic action on the pulmonary lesion ; it is its influ- 



SEA CLIMATES 595 

ence on the heart, bloodvessels, and nervous system that is important. 
If distinct disturbances in the structure or function of these organs 
are found, we must warn the patient against high climates. If there 
are strong reasons for sending him there, it must be done slowly- 
sending him first to a medium altitude and watching the effect, and 
when no harm is done he may be permitted to go higher and finally, 
if he bears it well, he may go up as high as 6000 feet or more above sea 
level. It is obvious that these experiments can only be made with 
economically independent patients. 

It has been repeatedly stated that hemoptysis is more likely to 
occur in high altitudes than on the plains, but this is not substantiated 
by facts observed by physicians with extensive experience in the 
mountains. All available evidence tends to show thai pulmonary hemor- 
rhages are no more frequent on mountains of moderate height (2000 to 
5000 feet) than in lower regions. Some authors, like Turban, state that 
it is even less frequent. 

The writer has sent to the mountains many patients with strong 
proclivities to bleed while in the city, and with the improvement in the 
general and local conditions, the tendencies to hemoptysis also dis- 
appeared. I have often been shocked by the advice given to patients 
who happen to get a hemorrhage while sojourning in the mountains, 
to leave at once, and they are in fact taken, while still bleeding, on a 
long journey. Moribund patients are thus brought to the city occa- 
sionally. 

Hemoptysis may occur in the mountains as well as in lower regions; 
it has not been proven that it occurs more frequently in the former 
places than in the latter. It seems, however, that the results of a 
copious hemorrhage may be more often serious in the mountains, 
especially in patients with impaired circulations, as has been shown 
by F. C. Smith. 1 His statistics show 56 deaths from pulmonary 
hemorrhages out of a total of 524 patients treated at the U. S. Public 
Health Sanatorium at Fort Stanton, New Mexico, with an altitude 
of 6231 feet. Ten per cent, of deaths from pulmonary hemorrhages 
are not seen in other places. 

Sea Climates. — Ancient physicians recommended sea voyages for 
consumptives. English medical men of the first half of the nineteenth 
century considered long sea voyages indicated in many cases of tuber- 
culosis. The fact that they have recently been abandoned shows that 
they have not met with success. But we often meet with patients who 
want to take a trip around the world as soon as they are told that 
they are tuberculous. In other cases in which it is desirable to remove 
the patient from his home surroundings the most feasible place is at 
the sea coast. In fact, there are many cases in which, as we have 
just mentioned, high climates are contra-indicated, and the patient, 
anxious for some decided change, asks whether a sea-coast resort is 

1 Tr. Nat. Assn. for Study and Prevent. Tuberc, 1908, iv, 246. 



596 CLIMATIC TREATMENT 

suitable for him. As was already emphasized, we must always consult 
the preference of the patient and send him to the place he chooses, 
unless there are strong reasons against it. 

It is obvious that the air on the high seas is pure and free from 
dust and microorganisms; but near the coast it is greatly influenced 
by the land climate, as well as by the industrial conditions in nearby 
cities. In fact, in some coast cities it is overloaded with dust and soot 
owing to factories in the neighborhood. 

But its moisture serves the purpose of equalizing the temperature; 
the seasonal differences are less pronounced. However, to this there 
are many exceptions, and before selecting a sea coast resort, it is best 
to inquire carefully into the local meteorological conditions. 

According to Schroder, 1 sea air has a profound influence on the heart 
and bloodvessels. The cardiac activity is increased and the pulse 
slowed. He explains it by the action of the strong air currents and 
the greater heat conductivity of the moist air; despite the decrease' 
in perspiration, the skin is better cooled and the bloodvessels contract. 
Reflexly, this causes a greater cardiac activity and the peripheral 
bloodvessels dilate, causing hyperemia of the skin. The result is 
strong circulation of the blood from the visceral organs to the periph- 
ery. The higher air-pressure causes slower but deepe 7 ' respiration, 
favoring better metabolism and increased excretion of carbon dioxide. 
The activity cf the skin, and especially of the mucous membranes, is 
greatly augmented. 

Sea voyages are not to be encouraged. "The vicissitudes of sea 
travel," says Guy Hinsdale, "the narrow cabins, and the difficulty 
of obtaining a suitable diet, even such common requisites as milk and 
eggs, should be enough to condemn sea voyages. Tuberculous patients 
ought not to travel more than is absolutely necessary. Imagine the 
bacteriological condition of a consumptive's stateroom, for instance, 
at the end of a month's voyage. What sea captain or steward would 
ever put such a cabin into sanitary condition for the next passenger?" 
Then it must be borne in mind that sea sickness is liable to do much 
harm. I have seen many hopeful cases of tuberculosis take a bad turn 
after a sea voyage during which they suffered from sea sickness. 

As a therapeutic measure sea voyages are therefore to be condemned. 
But patients who are known to bear the travel well and who do not suffer 
from sea sickness, may be permitted to cross the ocean when necessary. 
They are, however, to be warned against slow steamers; the sooner 
they get across the better; and they must be told that it is best for 
them to spend the greater part of the time on deck and avoid the 
close cabin and the stuffy smoking-room. 

Empirically, it has been found that incipient cases without pro- 
nounced constitutional symptoms often do very well at the sea coast, 
provided they observe the rules of healthful life. A slight tendency 

1 Brauer, Schroder, and Blumenfeld's Handbuch d. Tuberkulose, 1914, ii, 335. 



DESERT CLIMATES 597 

to hemoptysis is no contra -indication, but those who show proclivities 
to copious hemorrhages, especially in the advanced stages, should 
avoid the sea coast. Fibroid phthisis, as well as cases of tuberculosis 
with extensive pulmonary emphysema, are better off at the sea coast 
than at the mountains, and I have seen cases relieved or improved, 
though in inland climates they had been doing badly. Similarly 
cases with cardiac and renal complications, which cannot be sent to 
high altitudes, should be sent to the sea coast when a change is decided 
upon. Mild implication of the larynx is no coutra-indication. The 
cases of asthma and tuberculosis, in which dilatation of the heart is 
a strong feature, and which are not relieved, or are harmed, at a high 
altitude, should be sent to the seashore where they often recover their 
strength in a marvellous manner. The same is true of senile consump- 
tives with rigid arteries and rigid chests, in whom paroxysmal attacks of 
cough and expectoration are occasionally very annoying. They are 
often benefited by a stay at the sea. Phthisis with chronic bronchitis 
in which the amount of expectoration is excessive, is relieved at times 
in a sea climate. Mild forms of neurosis and metabolic disturbances, 
such as gout, diabetes, obesity, etc., when complicated by tuberculosis, 
do well at the seashore. 

Of course, far advanced cases with hectic or high continuous fever, 
or with laryngeal, intestinal, and renal complications, as well as acute 
progressive cases, should not be sent to the sea coast but should be 
kept at home. 

Desert Climates. — There yet remains to speak of desert climates 
in which many patients in this country have been cured by "roughing 
it." These regions may be of low or medium altitude. But their most 
important characteristic is the capriciousness of meteorological con- 
ditions; the changes are quick and extreme. The air is pure — there 
are usually not enough people to contaminate it — but it is frequently 
filled with dust and sand, especially after strong winds and storms. 
Of sunshine there is plenty, often to the detriment of the patient, who 
finds it hard to contrive a shelter against it. 

Because of the frequent changes in the weather, strong, often violent 
winds, these climates make very great demands upon the reactive 
powers of the patient, and lead to excessive expenditure of vital force. 
They are therefore suited only for those endowed with strong con- 
stitutions and who have ample recuperative powers. The very young 
and the very old and those with delicate constitutions should not be 
sent to the desert. Moreover, patients of the class just mentioned as 
proper cases for desert climate are not satisfied with climate alone. 
They demand, as a rule, also social life and amusements to distract 
them, and these they cannot get in those regions. 

It has been found empirically that patients with phthisis compli- 
cated by bronchitis and pulmonary emphysema, who expectorate exces- 
sively, often do well in these regions. Patients with phthisis compli- 
cated by renal disease may also do well, provided there is no arterio- 



598 CLIMATIC TREATMENT 

sclerosis. Occasionally, we meet a patient in a far advanced stage of 
the disease who has been "given up," but he decides to discard all 
comforts and pleasures of life and leaves for some desert region, and 
within a couple of years returns in excellent condition. These cases 
are rare, but they do occur. Unfortunately, they admit of no general- 
ization. 

A Warning. — Before leaving the subject of climatic treatment of 
phthisis, I want to emphasize the fact that it is not only good air but 
also good residence and above all good food that the patient must 
have if he is to recover. These three in combination are very difficult 
to obtain. William Garrott Brown, an American historian, who suc- 
cumbed to phthisis after making a vain fight against the disease, thus 
describes his experiences : 

" It is now seven years and more since I began my quest for a place 
and an arrangement to breathe freely and constantly the right kind of 
air, and eat in abundance the right kind of food, yet I can say with 
perfect honesty that I have not yet found anywhere the combination 
of these two factors of cure worked out satisfactorily at moderate 
cost for me and such as I am." He points out that American cookery 
is peculiarly exasperating — "that is to say, the cooking of such Ameri- 
cans, doubtless the majority, as can be induced to 'take boarders,' 
and particularly such as can be induced to take boarders who are 
sick. Many of these last, by the way, are such as have already failed 
to minister acceptably to boarders who are well. There is, as a rule, 
not merely unenlightened American cookery, but cookery simulated 
by no aspiration and but little competition; cookery seasoned with a 
lax indifference; cookery without any compelling need to be better, 
and with an obvious reason for being as careless and unlaborious as 
it can be and continue to be endured. To take 'lungers' at all, it 
would seem, confers rather than incurs an obligation. For is not that 
surrendering the chance of any other kind of gainful hospitality?" 

These are the reasons why many patients who have done well at 
home take a turn to the worse after a sojourn in the country for a 
few months. Physicians should bear this food problem in mind when 
sending their patients to boarding houses in the country, and when 
the place selected has an ideal climate but does not have the facilities 
for proper housing and feeding the patient, he is safer at home under 
a carefully regulated open-air treatment, as was already described. 



CHAPTER XXXVII. 
INSTITUTIONAL TREATMENT. 

Sanatoriums — We have shown that success in the treatment of 
tuberculosis can only be attained by gaining the confidence and the 
cooperation of the patient and retaining them over a long period of 
time, until the termination of the case. The old adage that rest, proper 
nourishment, and fresh air are effective as curative agents, holds 
good today. But these can only be of benefit when taken method- 
ically, and adjusted to the special requirements of each individual 
case. The tuberculous patient is usually an individual who has not 
led an exemplary hygienic life, as is proven by the fact that the error 
of his ways has been instrumental in reducing his natural and inherent 
resisting forces against the ravages of the tubercle bacilli. He must, 
therefore, be guided into a healthful mode of life. He must also be 
cared for in such a manner as to preclude the dissemination of the 
seeds of the disease among those who come into contact with him. 

These are some of the reasons why there have recently been estab- 
lished institutions with a view of solving the complex prophylactic, 
therapeutic, and social problems of tuberculosis. In these "sanato- 
riums" the patients are under the constant supervision of especially 
trained physicians who scientifically and methodically guide them 
along climatic, dietetic, and specific lines of treatment. The rules of 
rational life are minutely enforced, and the discipline is of a military 
character in practically all well-conducted institutions. 

As soon as a diagnosis has been made, the problem is at once pre- 
sented whether the patient should be sent to one of these sanatoriums 
or may be cared for at home w T ith an equal outlook for ultimate 
recovery. In deciding this question it is necessary to take into 
consideration many factors which are but rarely thought of. 

Scope of Sanatoriums. — The first sanatorium was established by 
George Bodington in 1840, as has already been mentioned (see p. 574). 
But he failed. Herman Brehmer established the first successful sana- 
torium in Germany in 1859, at a time when tuberculosis was considered 
incurable because of the teachings of Laennec and the experience of 
ancient physicians. In this country Trudeau established the first 
sanatorium at Saranac Lake in 1884 and met with considerable suc- 
cess, discharging cured patients, a thing which was in those days 
considered impossible. With the evolution of our knowledge of the 
etiology, pathology, and therapy of the disease, the role of the sana- 
torium has been greatly enhanced. It was expected that it would 



600 INSTITUTIONAL TREATMENT 

prove of great prophylactic value by affording places for the segre- 
gation and isolation of the bacilli " carriers;" that it would prove 
of immense therapeutic value because it was assumed that modern 
methods of climatic, dietetic, and specific treatment can only be 
carried out under the careful supervision of especially trained physi- 
cians; that it would prove of great educational value, teaching the 
patients a healthful mode of life which is in itself an important weapon 
in the struggle against the disease, and which may be followed by 
them after their discharge from the institutions. 

With these aims in view, numerous institutions have been established 
in nearly every country of the civilized world at an outlay of immense 
sums of money for buildings, equipment, and maintenance. In some 
countries the State or private insurance companies have provided the 
funds for the sanatoriums. The fact that within recent years the 
mortality from tuberculosis has decreased was considered striking 
proof of the valuable results attained, and the sanatoriums have 
been given the lion's share of the credit. 

But at present, after these institutions have been in existence for 
over thirty years, we hear inquiries from many competent sources 
whether they have done all, or the greater part, of what has been 
expected of them. Articles like that of Edward S. McS weeny, 1 
Medical Superintendent of the Sea View Hospital in New York, "Are 
We Getting Proper Value from Our Plant and Expenditure for the 
Tuberculous?" are becoming more and more frequent in our medical 
journals. T. D. Lister 2 is of the opinion that "too much is sometimes 
claimed as the result of the institutional training of patients." Con- 
sidering that immense sums of money have been invested in these 
institutions, it is but proper to inquire whether they have brought 
returns along therapeutic and prophylactic lines commensurate with 
the investment. 

Limitations of the Usefulness of Sanatoriums. — It seems that the 
pessimism as to the value of sanatoriums displayed at present is 
mainly due to the fact that too much was expected from them. They 
are no panaceas for phthisis. Some enthusiasts, who have advocated 
their erection and raised funds for the purpose, have in fact promised 
too much and when at present these institutions do not come up to the 
extravagant expectations of some, they are altogether condemned. 
This is as unjust. as the extreme enthusiasm of those who claimed 
that sanatoriums will solve the tuberculosis problem. In an official 
report signed by Clifford Allbutt, Lauder Brunton, Arthur Latham, 
and William Osier, 3 on the value of sanatorium treatment, it is stated: 
" In many cases, owing to the severity of the disease present, it must 
be useless; that in a few instances it is actually harmful; and that in 
many cases this method of treatment need not be carried out in an 
institution." 

1 Medical Record, 1915, lxxxvii, 94. 

2 Lancet, 1917, ii, 739 3 Lancet, 1911, ii, 180. 



SANATORIUMS 601 

Before pointing out the cases in which the sanatorium s may be 
utilized with benefit in the treatment of phthisis, we shall enumerate 
some of the shortcomings of this method of treatment: 

The number of sanatoriums is inadequate, and we cannot expect 
that there will ever be a sufficient number to provide for all tuber- 
culous patients, just as we cannot expect that all suffering from active 
disease can be induced to enter and stay within the institutions until 
the termination of the affliction. In the available institutions there 
is hardly place for 5 per cent, of the existing proper cases. To provide 
accommodations for all suitable cases in the United States, several 
billions would have to be invested in buildings and equipment, and 
then at least $100,000,000 annually for maintenance. Even the most 
enthusiastic of those engaged in the campaign for the control of 
tuberculosis are not hopeful of ever raising such enormous funds. 

Sanatoriums are expensive, and it is problematical whether the 
results attained within them could not be achieved in the vast majority 
of cases at a lesser expenditure with home treatment. It costs at 
least $2.00 per day to maintain a patient in a sanatorium. The experi- 
ment has never been tried on a large scale to spend that much money 
on a large group of patients treated in their homes consistently for 
many months. 

It appears that only the very rich or the very poor can afford insti- 
tutional treatment for months under present conditions. The former 
can pay any price, and the latter are cared for in enlightened cities 
by the State, municipal, or philanthropic institutions. But there is 
a large middle class which will only reluctantly agree to be treated as 
public charges, as is the case with clerks, small merchants, profes- 
sional persons, etc., who have been self-supporting until stricken by the 
disease. They cannot undertake to pay at least $20.00 a week for 
several months, and at the same time provide for those dependent on 
them. Neither are they inclined to enter State or municipal sana- 
toriums, and associate with persons who may be distasteful to them. 
Only when the disease has advanced far, often beyond repair, and all 
their own and their friends' resources have been exhausted, do they 
decide to enter sanatoriums as a last resort, and even then they often 
leave soon after entering because the surroundings are distasteful to 
them. This is the main reason why so few incipient cases, derived from 
these classes, are entering sanatoriums. 

It is very difficult to induce patients in the incipient stage of the 
disease to enter sanatoriums because they maintain that they feel quite 
well and resent the idea that they must live among "sick," or among 
"consumptives," and they often leave soon after entering for these 
reasons. The strict discipline, especially the unavoidable institutional 
atmosphere, is distasteful to the average human being who will resist 
all attempts to place him in an institution as long as he can. The 
policy of admitting only hopeful cases and discharging bed-ridden or 
dying patients, does not meet with the success worthy of the effort. 



602 INSTITUTIONAL TREATMENT 

Many patients refuse to enter sanatoriums because they do not 
want to have the stigma of tuberculosis which, they allege, will stick 
to them throughout their lives and may interfere with getting employ- 
ment under present conditions of private and municipal phthisiophobia. 

It can be stated without fear of meeting proofs to the contrary that on 
the whole, sanatoriums do not show better lasting results than properly 
conducted home treatment. In this country, hardly any State or munici- 
pal sanatoriums have published satisfactory reports with comparative 
statistics showing the results attained as compared with a similar 
group of patients treated in their homes. The most competent com- 
pilations of statistics have been published by Lawrason Brown and 
Pope 1 about the discharged patients from Saranac Lake, and by 
Herbert Maxon King 2 of the Loomis Sanatorium. To be sure, Brown 
shows that five, ten, and even eighteen years after discharge some of 
the patients were found alive, and even efficient at their occupations. 
But the average life of the consumptive outside of the institution, 
under any mode of treatment, has been found to be between six or 
seven years. Stadler 3 reports that five years after the onset of the 
disease one-half of tuberculous patients are found able to work without 
sanatorium treatment. There are similar statistics available for other 
countries, and I have no doubt that in the United States we would 
find conditions the same on careful investigation. King's conclusion 
as to the value of sanatorium treatment is that his inquiry "clearly 
demonstrates the uncertainty of apparent immediate results of 
treatment." 

This uncertainty refers mostly to relapses, which are to be expected 
when we consider the undulating course of phthisis, with its periods 
of remissions and of acute or subacute exacerbations. The few investi- 
gations that have been made of patients discharged from sanatoriums 
in New York show distinctly that a very high proportion have suffered 
from relapses of the disease, despite the fact that they have been found 
"apparently cured," or "improved" at the time of their discharge. 
Many have to be readmitted because of these relapses, and it has been 
said that the cure is so good and attractive that many patients like 
to take it several times. 

In estimating the problem whether sanatoriums bring returns com- 
mensurate with the money invested in their erection and maintenance, 
we must deduct those cases which suffer relapses, for obvious reasons. 
And when we do this, in addition to combining with them those who 
have been discharged because the sanatorium was of no benefit to them, 
and also those who died, we discover that the cost per successful case 
is enormous and hardly attractive to municipal and State authorities. 

The exorbitant cost of sanatoriums is shown in another way. It is 
well known that from 25 to over 50 per cent, of the inmates in the 

1 Am. Med., 1904, viii, 879; Ztschr. f. Tuberkulose, 1908, xii, 206. 

2 Tr. Nat. Assn. for Study and Prevent. Tuberc, 1912, viii, 82. 

3 Deut. Arch. f. klin. Med., 1902, lxxv, 412. 



SANATORIUMS 603 

institutions which aim at admitting but "incipient" cases are " closed" 
cases with negative sputum. Some authors are inclined to estimate 
that over 50 per cent, of these abacillary cases are in fact non-tubercu- 
lous. C. D. Partfit estimates conservatively that 33 per cent, of the 
abacillary cases which are classified as moderately advanced cases of 
tuberculosis are non-tuberculous. It is on these cases that such large 
sums are spent with a view of preventing and curing tuberculosis; they 
improve the statistics of success of the institutions. When we con- 
template the cost we are astounded. I assisted at the autopsy on a 
woman who spent twenty-six years continuously in a sanatorium and 
a hospital for advanced consumptives. We found that she had no 
active tuberculous lesion. Even if we count only $500 per year, the 
community wasted $13,000 on this woman, in addition to the loss 
of her work which might have been more than this sum if she had not 
been kept in an institution. Then, she kept out at least twenty-six 
patients who really needed hospital care. The sanatorium s and hos- 
pitals in this country all have numerous such cases. This is proved 
by the statistics of Ash and Washburn which we have already quoted 
(seep. 471). 

The educational value of the sanatorium s is beyond question, teach- 
ing, as they do, objectively the rules of healthful life. But the patients 
of the lower social strata, who make up the bulk of dependent con- 
sumptives, cannot, as a rule, continue along the hygienic lines which 
they have learned. Returning to the tenements, with rooms without 
windows or baths, coupled with a low earning capacity, one cannot 
live in the manner he learned in an institution. Relapses, which are 
likely under all circumstances, are inevitable for these reasons alone. 
In England Dr. Lister and many others have considered the educa- 
tional value of sanatoriums a great failure. 

On the other hand, the recent educational campaign carried on by 
the various antituberculosis agencies has done all that can be done 
along educational lines. In fact, the dispensaries with their social 
services, the day and night camps, etc., achieve educational, as well 
as therapeutic results which are, from a certain viewpoint, superior 
to and more far reaching than those of the sanatoriums and at less cost. 

Let us not overestimate the prophylactic value of the sanatoriums. 
It was hoped that by segregating consumptives, sources of infec- 
tion would be isolated. But we have already shown that this was a 
vain hope. Only "incipient" cases are admitted— so far as they can 
be found and induced to enter in time— while advanced cases, which 
are the most dangerous, because they expectorate myriads of tubercle 
bacilli, are rejected. The statement that institutional treatment is 
the predominant cause of the decline in the death-rates from phthisis, 
which has been expounded by Newsholme 1 with such vigor, is not 
supported by facts. Newsholme's figures have been demolished by 

1 Prevention of Tuberculosis, London, 1908. 



604 INSTITUTIONAL TREATMENT 

Karl Pearson, 1 one of the most competent authorities to judge statis- 
tics. In Germany — the home of the sanatorium — this claim has been 
abandoned during recent years. As was pointed out by Cornet and 
Robert Koch at the Antituberculosis Congress in London, there were 
at least 226,000 persons disseminating tubercle bacilli in Germany, 
and only 20,000 were cared for in institutions, and of these latter only 
4000 expectorated bacilli. This number could hot have had any per- 
ceptible influence on the morbidity and mortality from tuberculosis. 
In the United States conditions are the same. In recent attempts at 
prophylaxis of transmissible diseases no attempts are made to isolate 
cases when the number of " carriers" is large. This point has been very 
well elaborated by one of the best sanitarians, Charles V. Chapin. 
Why tuberculosis is an exception has not been shown. 

From the clinical standpoint, we are not in possession of reliable 
statistics showing that the mortality of patients who have been treated 
in sanatoriums is lower than that of those who have been cared for in their 
homes. We have already mentioned that the institutions in the United 
States have not published comprehensive data along these lines, 
excepting those by Lawrason Brown and King. In Germany, although 
long and apparently learned books and articles have been produced, 
they are just as much in the dark about this problem as we are in this 
country. The reasons are that the material is not comparable. A 
drastic illustration may be cited. In the selection of cases it is aimed 
at admitting only those in the incipient stage. The result is that at 
Grabowsee 45.2 per cent., and at Melsungen 97 per cent, of the patients 
have not shown any tubercle bacilli in the sputum. Ulrici reports 
that in 40 per cent, of the patients at Mulrose he could not make a 
positive diagnosis of tuberculosis, and Leube says that many patients 
who are admitted to sanatoriums in Germany are, when examined by 
military surgeons, found fit for the army and accepted. And during 
the recent war, the military authorities have found that a large propor- 
tion of these consumptives have made excellent soldiers. To be sure, the 
outdoor life and the regularity in habits which military service involves, 
as well as the nourishing food, may be some of the factors in improving 
many tuberculous patients, as some have suggested. But it seems to 
me that the greater number of these patients, though they had been in 
sanatoriums, were not at all tuberculous. They are derived from the 
class collectively grouped as "consumptives with negative sputum." 

It is obvious that statistics of such " consumptives" will show good 
and lasting results of treatment. In their book on the prognosis of 
tuberculosis Kuthy and Wolff-Eisner, reviewing the subject, say that 
exact and scientific data are not available to prove the value of sana- 
torium treatment; and Newsholme, who is a great believer in the 
benefits of institutional treatment, also says that there are no exact 
and comparable data available to prove it. 

1 Fight against Tuberculosis and the Death Rate from Phthisis, London, 1911; Tuber- 
culosis, Heredity, and Environment, London, 1912. 



TREATMENT FROM THERAPEUTIC VIEWPOINT 605 

Causes of Failure of Institutional Treatment from the Therapeutic 
Viewpoint. — While institutional treatment undoubtedly has its advan- 
tages, which will be shown later on, it is by no means the best and 
clinicians cannot approve of all the methods pursued in sanato- 
riums. The fact is, wholesale treatment of such a complex disease as 
phthisis is not ideal. Individualization is here of greater importance 
than in most other diseases. Says Albert Robin: 1 "One of the dis- 
advantages of the sanatorium is that it applies too often arbitrary 
principles to patients whose disease can only be relieved by individual- 
ized methods. It is for this reason that the practitioner who knows how 
to adapt the treatment to each of the small number of patients under 
his care, and to take cognizance of the temperamental indications, is 
qualified to manage a case of tuberculosis as well as, if not better than, 
the sanatorium doctor who has under his care a large number of 
patients of whose individual idiosyncrasies he is ignorant, at least 
for a time, and must therefore have a strong tendency to subject them 
all to the same method of treatment." This refers to private sana- 
toriums, in which the patients must be catered to if they are to be 
retained for months. In State and municipal sanatoriums, where the 
poor and dependent patient faces starvation if he leaves the institu- 
tion, the trouble is of a diametrically opposite character. The fact 
that a large proportion of patients leave before the physicians discharge 
them shows that they cannot be satisfied. 

This lack of individualization in treatment is seen in many ways in 
the sanatoriums which are hotbeds of therapeutic hobbies. But this 
is usually not so harmful as the uniformity of the diet in institutions. 
Mass feeding is difficult at best and can only be carried out in jails, 
where the inmates have no choice, or in armies during tear. In a discus- 
sion on the sanatorium problem in England, T. D. Lister 2 thus sum- 
marized the food question: "It is badly cooked, badly served, from 
ignorance or lack of sympathy for human weaknesses, from unneces- 
sary monotony in the daily menu. For the convenience of the staff and 
store room there is a melancholy recurrence of the same food after the 
same intervals in some sanatoriums. Loss of interest and loss of 
appetite result. Patients, staff and doctors often become institu- 
tionalized. There is always a risk of deterioration in official clinicians." 
To subject to the same dietary tuberculous patients in different stages 
of the disease, with different individual capacities for digestion and 
assimilation, who have been brought up on and adapted to different 
kinds and preparations of foods, is bound to meet with failure. For 
this reason we find that complaints about the quantity and quality of 
the food are universal in public sanatoriums, and to some extent in 
private institutions where food is served a la carte. 

It can hardly be expected that municipal, State and philanthropic 
sanatoriums should supply food a la carte; it will always be table 

1 Traitement de la tuber culose, Paris, 1912, p. 67. 

2 Lancet, 1917, ii, 739. 



606 INSTITUTIONAL TREATMENT 

d'hote. And for this reason resentment on the part of the patients 
is to be expected. To be sure, these institutions are always filled and 
there are long waiting lists. But when patients leave before they are 
discharged, we may safely assume that the cost incurred during sev- 
eral weeks or months for their maintenance was, to a large extent, 
wasted. 

In American municipal sanatoriums of the large industrial cities 
the failure in this regard is even greater than in other countries, 
because we must care for tuberculous immigrants of various nation- 
alities, whose tastes differ extremely as regards food and its preparation, 
as is shown elsewhere in this book. 

These are some of the drawbacks of sanatorium treatment. It is 
for these reasons that the municipal and State sanatoriums in many 
cities of the United States are not filled with a desirable element, but 
contain a large proportion of undeserving individuals. "My efforts 
are not going to be devoted to coddling tramps and other parasites," 
exclaims in despair Dr. Edward S. McSweeny, the Medical Superin- 
tendent of the Sea View Hospital in New York. These are also the 
reasons why the best elements of the tuberculous population in this 
country will always have to be cared for in their homes, as is the case 
at present. 

Indications for Institutional Treatment. — But there are many cases 
of tuberculosis which cannot be treated in any other place than in insti- 
tutions. In fact, anyone with experience in a large city is convinced 
that tuberculosis cannot be managed without the aid of institutional 
treatment. Of the cases which are suitable for sanatorium treatment 
and would be lost without it, we may mention the following : 

Among well-to-do patients we meet with many who, for various 
reasons, cannot be cared for in their homes. To send them to the 
country without control may prove disastrous, because the foolish 
and reckless rich show at times greater lack of self-restraint than the 
stupid poor. They are best cared for in private sanatoriums in which 
most of the drawbacks of the public institutions are eliminated. They 
may be sent to sanatoriums for a short stay, over the hot summer 
months, or for outdoor treatment for the relief of an acute exacerba- 
tion, etc.; or for a long period till the disease is arrested. Great care 
should be taken that they do not become egocentric, excessively 
introspective, or hypochrondriacs, which is not unusual. 

Among the poor, and those who have become dependent because of 
the disease, we meet with a large number of patients who have no 
family to care for them during their illness and, with or without funds, 
they are unable to find lodgings under present conditions of rampant 
phthisiophobia. Many boarding houses bar persons who cough; and 
at times even near relatives are overtaken with a sense of stupid fear 
of infection, and want to get rid of the unfortunate patient. For these 
there is left nothing but to go to a well-regulated sanatorium. 

There is a large number of phthisical patients who notoriously lack 



INDICATIONS FOR INSTITUTIONAL TREATMENT 607 

will power to carry out the most important of the measures pre- 
scribed for them and, remaining in the city, they are apt to be tempted 
by the opportunities for gay life, or even excesses. They are better 
off in sanatoriums. 

On the other hand, there are many who show all willingness to do 
everything that is conducive to the cure of the disease, but they 
have not the funds to pay for capacious rooms in a desirable part of 
the city, for good nourishment and medical attendance. Tuberculosis 
is after all the most expensive of diseases, not only for the special 
and costly nourishment and residence which are required, but mainly 
for the long time the patient must remain idle, and the savings of years 
may be exhausted before he can resume work. While most of these 
can be, and are, well cared for in the clinics, the day and night camps, 
found in every large city at present, we meet with many who, for 
obvious reasons, are better off in sanatoriums, at least for short stays. 

Most phthisical patients should leave the city during the hot summer 
months, and those who cannot raise the funds for the purpose are 
proper charges of the sanatoriums. Indeed, if the sanatoriums were 
not filled with lazy, undeserving tramps and vagrants who remain for 
years in the institutions, and when discharged from one, soon gain 
admission to another, they could well care for the just mentioned class 
of patients. It seems to me that the German system of admitting 
tuberculous patients for three or four months is much superior to ours, 
where they are often kept indefinitely. The result is that the patients 
must wait for months before beds are vacant for them, and truly 
incipient cases, left without proper care while waiting for admission, 
may become advanced. 

The longer we are up against the problems presented by tuberculosis 
in the city, the more we are convinced that the public sanatoriums 
ought to be converted into hospitals which admit patients on short notice, 
keep them for a few iveeks, a month or two, until they regain their strength, 
and are fit for treatment in the clinics. Patients who suffer from acute 
exacerbations during the long, chronic course of phthisis could then 
be cared for. Inasmuch as municipal institutions are now in abun- 
dance near cities, this could easily be accomplished. 

But sanatoriums still work on the theory that they are to cure their 
patients, which they cannot do in more than 5 or 10 per cent, of cases, 
which is, in fact, not more than home treatment accomplishes. 



CHAPTER XXXVIII. 
DIETETIC TREATMENT. 

Economic Aspects of Dietetics for Consumptives. — Because phthisis 
is accompanied by wasting of the body it requires careful, generous, 
and at times excessive nourishment with a view to covering the deficit 
created by the extravagant drain resulting from the toxemia, fever, 
loss of appetite, disturbed digestion, faulty metabolism and con- 
comitant emaciation. Cornet suggests that the rapid waste of the 
tissues tends to hasten absorption of the proteins surrounding the 
tuberculous foci and thus, at the same time, inhibits the natural pro- 
cess of healing by means of induration and also furthers the periph- 
eral dissemination of the bacilli. Inasmuch as the disease finds 
most of its victims among the poor and destitute, or causes destitu- 
tion and despondency in those who had been self-supporting before 
its onset, the dietetic problems are not only of a physiological nature, 
but also have important economic bearings. It is self-evident that a 
dependent consumptive must not be prescribed food which is beyond 
his reach financially. 

In my experience the dietetics of phthisis are, in fact, more depen- 
dent on the financial resources of the patient than on the careful calcu- 
lation of the number of calories contained in the various foodstuffs. 
Considering the variety of dietaries which have been urged by various 
authors, in this disease, and that each author claims good results with 
his method, it is obvious that no specific diet has been devised which will 
suit every case. In fact, all that can be stated is that tuberculous patients 
need food, just like other persons who are underfed, but they usually need 
more of it. 

Need for Individualization of Diet. — Most of- the studies in the 
dietetics of phthisis have been carried out in sanatoriums, some of 
which have had sufficient funds for an extravagant diet, while others 
with meager finances have shown similar results. But the lessons 
from institutional experience are not applicable in their entirety to 
patients treated in their homes. On the other hand, the time-honored 
advice given to tuberculous patients: u Eat plenty of milk, eggs and 
meat," is often decidedly harmful to those who follow it implicitly. 

There is great urgency for individualization of the diet in pjhthisis; 
it is important that the diet should be adapted to the needs of the 
patient and not to the disease. The "personal equation" counts for 
more than the disease. 

There is no doubt that the failure of institutional treatment of 



SUPERALIMENTATION AND FORCED FEEDING 609 

phthisis is, in a large measure, due to negligence in this regard. Whole- 
sale feeding is usually disastrous for human beings. The food in 
first class table d'hote restaurants is usually unbearable to the average 
person when relied on continually for a considerable time. It is impos- 
sible to make up a menu which will suit the palate, digestive capaci- 
ties, and functions of one hundred patients in an institution where 
they must remain for months. The difficulties are greater with 
tuberculous patients whose gastric functions are very often deranged. 
Tuberculous patients cannot be treated like soldiers in the army, 
or prisoners, if we are to succeed in our aims. 

It is not true that two kinds of food of different composition, but 
theoretically of the same nutritive value, will invariably be of the 
same digestibility, or produce the same effects. It may be calculated 
in the laboratory that a portion of beefsteak, roast beef, poultry, sau- 
sages, stew, cheese, potatoes, cereals, bread, milk, eggs, etc., contains a 
certain proportion of proteins, fat, and carbohydrates, and will liberate 
a certain number of calories when burned in the body. In fact, we 
know that the intrinsic value of three eggs is equivalent to about 
100 grams of red meat, while 100 grams of bread is approximately 
equal to one egg, or 30 grams of beef, or 200 grams of potatoes, or 
280 grams of milk. But very often a consumptive assimilates three 
boiled eggs more easily than 100 grams of beef, or 300 grams of bread. 
At times the patient assimilates 250 grams of milk better than 200 
grams of potatoes. Because of the personal equation many patients 
refuse to thrive on scientifically prepared dietaries. An Irishman 
resents spaghetti, an Italian refuses Irish stew^ a German prefers 
sausages to the English roast beef, etc. 

For these reasons, in prescribing a diet for a patient we must always 
take into careful consideration his habits of life, the foods upon which 
he has been raised, and his personal likes and dislikes. Even when a 
change is imperative, it is dangerous to institute it suddenly, and 
we must make a strong effort to fit the diet to the one the patient 
has been used to. The factors which should guide us are the presence 
or absence of anorexia, fever, constipation, diarrhea, etc. 

Superalimentation and Forced Feeding. — With a view of replenish- 
ing the wasted tissues, especially in those who are by nature bad eaters, 
it has been suggested that superalimentation, or even forced feeding, 
is indicated in most cases of phthisis. It has been observed that 
occasionally an emaciated patient gains in weight under such a regime, 
and some authors have advised that all sufferers from phthisis should 
be "stuffed." Even Debove's method of introducing food through 
the stomach tube into those who would otherwise not consume large 
quantities of nourishment was in vogue for some time until it was 
found that the gain in weight which forced feeding produced in some 
cases was not necessarily an indication that the lesion in the lung had 
improved . It was also found that many patients under forced feeding, 
with or without the stomach tube, may gain in weight and improve 
39 



610 DIETETIC TREATMENT 

otherwise for some time, when suddenly the gastro-intestinal tract 
rebels, and within a few days they lose more than they had gained in 
several months. 

Estimation of the Nutrition of the Patient. — In our attempts at 
estimating the results of certain dietetic methods in tuberculosis we 
cannot always be guided by the scientific determination of the num- 
ber of calories ingested by the patient every day; nor even by the 
quantity of proteins, fat, and carbohydrates which the patient has 
consumed. Attempts along these lines have proved futile in practice; 
they have not given us a diet which will suit all, or the vast majority, 
of cases. It seems that only clinical observation of the individual 
patient, his state of nutrition, his digestive capacity and the assimi- 
lability of the ingested food are of value in this regard. 

We aim at increasing the amount of nourishment so that the patient 
shall gain in weight and remain stationary at somewhat above his 
usual, or normal, weight before the onset of the disease. While in 
the vast majority of cases a gain in weight is a good index of the 
value of the diet, it is, however, often liable to mislead. Fattening by 
no means goes hand in hand with enhancing the resistance against the 
tuberculous toxemia in every case. We also meet with cases with hardly 
any gain in weight, in fact remaining under the standard weight, yet 
the lesion in the lung heals, and recovery is good. 

"The main object of dietetic treatment," says Brown, 1 "is to enable 
the patient to regain his lost weight, but not to make him a flabby, 
breathless mass of inert fat." Excessive nourishment, which increases 
the weight of a patient more than two or three pounds per month 
on the average, is apt to result in an overload of fat and water without 
any utility. We should strengthen, but not fatten the patient. " When 
a workman has to perform hard work, he eats meat," says Daremberg; 2 
"the consumptive has to perform a very hard task, the task of re- 
pairing his wasted body." In fibroid phthisis obesity is not rare — 
"obesite toxique" of the French — and is often more annoying to the 
patient than the symptoms in the respiratory organs. 

In the average case we may judge the progress of the disease by 
following the weight of the patient, provided we also take other factors 
into consideration. With the increase in weight there should also be 
an increase in strength; physical examination should also show 
regression of the signs in the lungs, the cough should be ameliorated 
and the quantity of sputum decreased. With such signs, a slow and 
persistent gain, finally reaching ten to fifteen pounds higher than 
the patient's normal weight before he w T as attacked by phthisis, indi- 
cates that we may be satisfied that the diet is good. 

Do All Tuberculous Patients Need Special Diets? — A large propor- 
tion of phthisical patients, probably one-third of all, have good appe- 
tites and digestion. In fact, even febrile consumptives are seen without 

1 Osier's Modern Medicine, i, 482. 

2 Les differentes formes cliniques de la tuberculose pulmonaire, Paris, 1905, p. 149. 



VARIETY IN DIETETIC TREATMENT 611 

anorexia which accompanies nearly all other fevers. The prognosis 
is good so long as they retain their gastro-intestinal functions. They 
may be told that a moderate increase in the quantity of food they have 
been accustomed to eat is sufficient and, when possible, they should 
increase somewhat the quantity of proteins and fats, provided the 
stomach does not rebel. 

If the constitutional symptoms are in abeyance, or disappearing, 
and the signs in the lung show that the lesion is cicatrizing, we should 
not worry about a lack of gain in weight, or even when they show 
a few pounds less than their normal weight. A patient with a good 
appetite and digestion needs no special diet; he should eat just like 
any other person, or a little more, if he can without inconvenience. 
On this point all authorities agree today. Thus, King 1 says: " In the 
absence of certain complications, a diet which would suffice for the 
same individual under normal conditions of life will doubtless, with 
very slight modifications, meet the requirements in the presence of 
tuberculosis, the more especially during that period of the disease 
when constitutional symptoms are either absent or but slightly mani- 
fest." Paterson, 2 whose patients work at graduated labor, gives 
them "a liberal diet which consists of the ordinary food which the 
working classes provide for themselves when they are in a position to 
afford it." In fact, patients who tend to become excessively fat have 
their diet reduced in quantity. 

On the other hand, patients who lose progressively in weight and 
strength, are anemic and debilitated despite the rest which is rigidly 
enforced, need more and better food if they are to recover, or hold their 
own, in the struggle with the disease. But even here superalimentation 
must be carefully adapted to the digestive capacity of the patient. 

It may be stated as a general rule that the suggestion of some 
authors that in such cases the patients must consume between 4500 
and 6000 calories daily is a dangerous one. Experience has taught 
that one who will not recover, or hold his own, on a diet of 3500 calories, 
will not recover at all. Professor Fisher 3 says : " We may feel satisfied 
that given proper food elements, the average tuberculous patient can 
be successfully nourished on 3000 calories per day; in other words, 
on no more than is usually consumed by the sedentary man." N. 
D. Bardswell and John E. Chapman 4 have arrived at the same con- 
clusion after a thorough experimental study of the subject. 

Variety. — The first principle to be observed in the diet of the tuber- 
culous patient who is losing weight is variety, both as regards nutritive 
principles as well as appetizing qualities. There is nothing more 
abhorrent to a tuberculous patient, and to a large extent to all sufferers 
from chronic diseases, than homogeneity of diet. No limited and 
exclusive diet can keep a patient well for any length of time because 

1 Sixth Internal Cong. Tuberc, 1908, i, 719. 

2 Ibid, p. 893. 3 Ibid, p. 694. 
4 Diets in Tuberculosis, London, 1908. 



612 DIETETIC TREATMENT 

it does not respond to the urgent demands of the different organs and 
tissues of the body. It does not stimulate the secretions of all the 
digestive glands. If an exclusively animal diet is taken, only the 
gastric juice is stimulated, while the saliva, pancreatic juice, bile, and 
intestinal juices are not utilized and, remaining free in the gastro- 
intestinal tract, are apt to act as irritants and produce diarrhea which 
is exhausting, or constipation which is harmful in other ways. 

We often meet with patients who have been given diet lists in 
which four or five meals are listed for the day. But any appetite 
they may have had before the list was consulted promptly disappears, 
because it shows the foods which have been given them for months 
without any appreciable variation. Many patients who have followed 
the injunction ''plenty of milk and eggs" have engendered such an 
aversion to these articles that the mere mention of an egg is sufficient 
to disturb the slight appetite for other foods which was called forth 
by hunger. It is always advisable to consult the patient as to the kind 
of food he prefers or longs for and, if there are no contra-indications, 
to give it to him. 

Precautions to be Taken when Overfeeding Patients. — Before a 
patient is urged on to a course of superalimentation certain precau- 
tions are to be taken : He must be carefully examined with a view of 
ascertaining whether or not he can stand additional feeding. Those 
showing signs of arteriosclerosis, nephritis, gall-stones, nephrolithiasis, 
or gout, should not be allowed superfeeding, especially with animal 
proteins. It is likely to throw a considerable strain on the kidneys, 
or even produce albuminuria. The condition of the stomach is to be 
ascertained, and those having dilated organs, or disturbances in the 
tonicity and motility of the viscus, are to be treated for these troubles 
when practicable. The appetite is of great importance. Although 
we may succeed with some patients in urging them to eat irrespective 
of the appetite, we will fail with many. 

Proper preparation of food goes a long way in counteracting anorexia; 
Dettweiler, who made a great success with his sanatorium, said that 
the kitchen was his pharmacy. It is better to give the patient small 
quantities of each of several dishes, well and appetizingly prepared, 
than large quantities of one or two dishes. The fact that the food value 
is theoretically sufficient in the latter case does not alter matters. 
With some patients animal food should predominate, with others eggs, 
and with still others, milk. The diet must be frequently changed, 
especially when the digestive tract shows signs of rebellion. 

With well-to-do patients these are simple matters, but with the poor 
the problem is often hard to solve. The writer usually sends for the 
mother, wife, or sister of the patient and gives her directions along 
these lines. 

Bearing in mind that the disease is likely to last for months, if not 
for years, we must spare the digestive organs, the cornerstone of 
phthisiotherapy, as they have been called, and not overburden them 



PROTEID FOODS 613 

with work. The first imperative principle is proper mastication. 
But regularity in meals is of the same importance. The menus 
of some authors mention six and more meals a day, which are 
excessive in my experience. Three, at most four meals a day are 
sufficient for most patients, and afford some rest to the stomach 
between the meals. At all events, the stomach must be given a 
complete rest during the night, which can be done by avoiding all food 
between 9 p.m. and 7 a.m. 

Proteid Foods. — Experimental researches of Richet and Hericourt 
and others have proved conclusively that when ingested raw, animal 
foods have an especially beneficial effect in tuberculosis. The specific 
effect seems to reside more in the juices of the meats than in the fiber. 
Herbivorous animals, like the cow, are more prone to tuberculosis 
than carnivorous animals, as the dog. 

The best source of proteins for a tuberculous patient is animal 
food; the proteins of vegetable origin are not so easily assimilated. 
Meats possess all the qualities which are necessary for the nutrition 
of the consumptive. To be sure, there are some who maintain with 
Kellogg 1 that a low protein diet is productive of better results, and urge 
vegetable proteins in the dietetic management of the malady. It is, 
however, an every-day observation that the animal proteins do not 
tax the digestive organs to excess and, excepting in those who suffer 
from some form of dyspepsia, they can be taken by most consumptives 
without difficulty in comparatively large quantities. Beef, mutton, 
lamb, poultry, game, fish, oysters, eggs, milk, cheese, etc., offer a wide 
range of choice for variety. 

Those who have no natural abhorrence for raw meat may have it 
with great benefit — zomotherapy was at one time very popular, and 
should be utilized, when tolerated. Some patients are not averse to 
taking small pieces of raw beef, dipping it in tomato sauce and eating 
it. It is, however, better to mince or chop it, and eat it between two 
slices of bread as a sandwich, but it should be seasoned to taste. 
The vast majority of patients, however, prefer roasted or boiled beef, 
mutton, poultry, etc. It must be mentioned that when roasted or 
broiled, meats should be rather underdone and, on the whole, they 
should be changed often. 

But it should never be excessive; we cannot rely on animal foods 
exclusively in nourishing a tuberculous patient. To supply a patient 
with 5000 calories per day, it would be necessary to gorge him with 
six and a half pounds of meat, or thirty-six eggs, or five quarts of 
milk, or two pounds of cheese. This would be too much— no human 
being could take it with impunity for any length of time. For this 
reason other foodstuffs are necessary in addition to the animal food. 
The most the average consumptive should have is about three-fourths 
to one pound of meat, and, when taken raw, it should not exceed one- 

> Sixth Internat. Cong. Tuberc, 1908, iii, 740. 



614 DIETETIC TREATMENT 

half pound per day. When this is taken with one pound of bread, 
three eggs, one quart of milk, eight ounces of potatoes, and four 
ounces of fresh vegetables, the diet is complete. 

Attempting to feed tuberculous patients with proteins we are often 
confronted with the high cost of animal foods. In many cases we must 
attempt to supply proteins from fish, which are much cheaper than 
beef, veal or poultry. Now, beef contains from two to three ounces 
of protein per pound. Fresh fish, such as haddock, cod, halibut, perch, 
salmon, mackerel, or shad, contain from one-and-a-half to two-and- 
a-half ounces, while the commoner dried fish contain even more pro- 
teins, up to three ounces per pound. Proteins in a digestible form 
may thus be purchased, when fish are used, at from 30 to 50 per cent, 
of the cost of the same amount when consumed in meats. Either for 
the sake of variety, or because of imperative saving in cost, fish should 
not be neglected from the diet of the tuberculous. 

A consumptive needs more protein foods than a healthy person 
because the disease destroys the tissues, especially the muscles, and 
there are no better tissue builders than proteins. But we must not give 
them at the expense of other foods. It is unnecessary, even dangerous, 
to give more proteins than are required for repairing the tissues; other- 
wise it is likely to prove more disastrous than to a healthy individual. 
These evils are, as the researches of Chittenden, Mendel, Folin, Herter, 
Metchnikoff, Tissier, Combe, Kellogg, Turk, and others show: (i) 
that protein which is not used for tissue building is not " burned clean," 
as are fat and carbohydrates, which yield merely water and carbon 
dioxide, but leave behind " clinkers" in solid form — for instance, uric 
acid; (2) that meat proteids also contain such "clinkers" in their 
extractives, which are superadded to the similar products from the 
metabolism of proteins in the body; (3) that all protein which is not 
absorbed is subject to putrefaction in the intestinal canal, and gives 
rise to toxins which are partially absorbed and produce injuries of 
various kinds to the organism (Irving Fisher). 

Milk. — Milk has been considered for centuries a good food for 
consumptives — Aretseus already spoke of it in this connection. It 
contains more than 10 per cent, of nutritive matter, albumin, fat, 
sugar, and salts. But this does not mean that it is good to use it 
exclusively for our patients as has been done in the well-known "milk 
cures." If we wanted to supply all the requirements of a patient it 
would be necessary to make him ingest five to seven quarts of milk 
per day. In a few weeks his stomach would be dilated two or three 
times its normal dimensions. 

But with other foodstuffs it is excellent because its nutritive prin- 
ciples are easily digestible in the stomach and intestines, and it contains 
no toxic substances. It is just as good for a patient with fever as 
for one who is afebrile. A quart of milk is equivalent in fuel value 
to a pound of lean meat, or eight eggs. It is thus evident that, from a 
certain standpoint, it is a much cheaper source of fuel than either 
meat or eggs. 



EGGS 615 

It is best given between meals in the form of drink, and may be 
added to many other foods, especially cereals. But it must not be 
abused; patients who gorge themselves excessively with milk lose 
their appetite for other foods. Between a pint and a quart of milk 
per day is to be considered the maximum for the average patient. 

There are patients who do not bear milk very well. In some it pro- 
vokes lactic and butyric acid fermentation in the stomach; this 
viscus becomes dilated and the complicating hyperchlorhydria favors 
spasmodic contraction of the pylorous. In others, the milk clots 
excessively in the stomach, large solid curds are formed which irritate 
the mucous membrane and cause nausea and vomiting. In some 
patients the milk passes the stomach without difficulty, but it pro- 
duces trouble in the intestines — gaseous distention and diarrhea. I 
have seen many cases of diarrhea in consumptives, which were thought 
to have been caused by intestinal ulcerations, but which disappeared 
with the withdrawal of milk from the diet. 

The milk may be rendered more digestible by diluting it with alka- 
line waters, or lime water, but then the total quantity consumed must 
be reduced. It is usually more easily digested when given with some 
cereal, like oatmeal or rice. Atwater found that milk is more easily 
digested when it is part of a mixed diet. When consumed alone the 
proportion digested was: proteins, 91.2 per cent.; carbohydrates, 
86.3 per cent.; and fat, 92.8 per cent. When milk and bread made 
up the diet, the amount digested was: proteins, 97.1 per cent.; 
carbohydrates, 98.7 per cent.; and fat, 95 per cent. 

Fermented milk is often more easily borne in large quantities when 
the pure article is not sustained. We may try koumiss, keffir, or the 
various preparations of buttermilk, which are at present supplied by 
most milk dealers at reasonable prices, or may be prepared at home 
with cultures or tablets of lactic acid bacilli. 

Cheese is an excellent food for consumptives. But we should avoid 
the highly seasoned varieties. Cream cheese and ordinary pot cheese 
contain considerable nutritive elements and do not provoke cough or 
gastric irritation. 

Eggs. — Eggs are considered an excellent food for tuberculous patients 
by the profession and the laity. In assimilability they exceed any 
known food excepting milk and oysters. They contain enormous 
quantities of albumen and fat. The white of an egg consists of pure 
protein which is as digestible and nourishing as that of beef; the yolk 
contains 25 per cent, of fat, 15 per cent, of protein, and also nuclein, 
lecithin, iron, and salts. Eating one dozen eggs per day, a consump- 
tive could feed himself, and pushing it to twenty eggs he would absorb 
the equivalent of two and a half pounds of beef, because an egg of 
50 grams is equivalent to about 35 grams of moderately fat beef, or 
128 grams of cow's milk. In other words, they contain over 700 
calories per pound; the whites yield 250 and the yolks 1700 calories 
per pound. But an exclusive egg diet is just as bad as an exclusive 



616 DIETETIC TREATMENT 

meat diet. Too much fat is introduced into the stomach and con- 
gestion of the liver is the result, while with an exclusive meat diet, 
congestion of the kidneys occurs. 

It appears, however, that eggs have been abused as an article of 
food for the tuberculous. Many of the gastric derangements of the 
tuberculous patients can be traced to the abuse of the eggs as a food. 
Most patients consume them raw, and it has been found that raw 
white of egg is decidedly indigestible. Mendel and Lewis 1 pointed out 
that, when given to animals, raw eggs give rise to diarrhea. W. G. 
Bateman 2 found that in dogs, when given in considerable quantities, 
it sometimes causes vomiting and invariably produces diarrhea. 
Pawlow found that raw white of egg only partly stimulates a flow of 
gastric juice. But Bateman shows that cooked egg-white, on the con- 
trary, calls forth an abundance of juice and unites easily with hydro- 
chloric acid. Egg-white remains but a while in the stomach, and 
escapes in gushes through the pylorus. "Once in the intestines the 
native egg-white continues to oppose the digestive enzymes, for it has 
remarkably strong antitryptic properties. . . . Not only does it 
resist digestion itself, but it prevents the digestion of other easily 
digested proteins." It is very poorly utilized. In large doses, from 30 
to 50 per cent, of that ingested is wasted by being ejected with the 
feces. In normal feces albumin is never found. In contrast with egg- 
white, egg-yolk has been found to be well digested and utilized. 

Clinicians who have the care of tuberculous patients should there- 
fore heed the following warning of Bateman: "A substance which 
fails to stimulate a flow T of gastric juice and is antipeptic, which hurries 
from the stomach, calls forth no flow of bile, and strongly resists the 
action of trypsin, which is poorly utilized and may cause diarrhea, has 
evidently little to recommend it as a foodstuff of preference for the 
sound person, let alone for the invalid." 

On the other hand, cooked egg-white is easily digested and well 
utilized by the economy. All that is necessary to prepare egg-white 
for digestion is to heat it to 70° C. Under no circumstances should a 
tuberculous patient be permitted to consume several raw eggs a day. 
They should invariably be boiled. In fact, in my experience eggs may 
be fried, scrambled, or prepared in any way; so long as they are not 
consumed raw, they make an excellent food for tuberculous patients. 

But there are some exceptions. Those who suffer from derange- 
ment of the function of the stomach and the liver do not bear eggs very 
well and they may have to be discarded. The same is true of patients 
who have an idiosyncrasy to eggs and get colicky pains in the abdomen, 
vomiting or diarrhea from an egg. 

Four to six eggs per day is about the maximum which a patient 
should be allowed, if we are to retain the functions of the stomach 
and liver. In most cases less should be given. 

1 Jour. Biol. Chem., 1913, xvi, 55. 

2 Ibid., 1916, xxvi, 263; Am. Jour. Med. Sc, 1917, cliii, 841. 



FATS 017 

Fats. — While the amount of fat necessary for the average consump- 
tive has been exaggerated by many authors, it is nevertheless a fact 
that a diet containing a surplus of easily assimilated fat is the best. 
It must, however, be borne in mind that the capacity for digesting 
and assimilating fat varies with the individual. In some patients 
an increase in the amount of fat is immediately followed by gastro- 
intestinal disturbances. Many people cannot digest fat meats like 
bacon, ham, etc. We have already mentioned that many patients 
have shown intolerance for fat even before the onset of the' disease. 

I have found that butter is superior for our purposes, and it has given 
me results as good as cod-liver oil, which has been popular for centu- 
ries. I direct my patients to cut their bread in thin slices and cover 
them with heavy layers of butter; mixing butter with mashed potatoes 
and other foods. As much as six to eight ounces of butter can thus 
be consumed daily by the average patient without gastric or intestinal 
disturbances. Those who like to and can consume large quantities of 
unskimmed milk may get the greater part of their fat in this manner, 
while cream and certain kinds of cheese are also rich in fat. In look- 
ing for sources of easily digestible fat we must not forget fish: Sal- 
mon, pompano, sardines, shad, fish roe, caviar, etc., are very good 
for this purpose. Those who have great tolerance for fat may also 
take in addition to butter, cream, cream cheese, fat meat, and bacon. 

The quantity of fat a patient should consume varies according to 
the season, the kind of food he has been accustomed to eat, his toler- 
ance of fat, and the condition of his gastro-intestinal tract. Of course, 
those who are obese, and they are not rare among quiescent cases, 
should be discouraged from eating an excessively fat diet. 

It has been my experience that a patient without preexisting gastric 
disease can consume six ounces of fat every day for months with bene- 
fit. But now and then one is met who shows a decided inclination to 
fat intolerance. It is my impression that in most cases it is due to the 
excessive amounts of improper fats which have been forced upon 
them. It has been suggested by Tibbies that when a patient cannot 
take fat, the proteins can be increased; 100 grams of proteins will 
yield 40 grams of fat. Proteins alone will never fatten a patient; 
6.5 pounds of lean meat, or 5.5 pounds of lean and fat meat would be 
required to supply the daily requirements of carbon for an ordinary 
person; therefore some other source for carbon must be found. 

We must guard against quick fattening, "stuffing," of tuberculous 
patients. Often consumptives are urged to eat plenty and some ingest 
enormous quantities of food and gain remarkably well. Taking their 
weight weekly, and finding that it keeps on increasing, they are 
encouraged to continue in this manner, and at the end of three or four 
months the gain may be as much as thirty or even forty pounds. But 
to their dismay they have not been rehabilitated in other respects; 
they are as yet unable to work, and are in fact weaker than before. 
The weight they have put on is only an added burden, which is not 



618 DIETETIC TREATMENT 

only useless, but actually incapacitating. In addition, they suffer from 
annoying dyspnea. Physical examination shows that the process in the 
lungs has not improved; perhaps it has distinctly extended. Carefully 
and guardedly reducing these patients has often been of great benefit. 

Carbohydrates. — In the eagerness to supply the body of the patient 
with proteins and fat, carbohydrates must not be neglected from the 
diet. They are, as a rule, easily digested and assimilated, and they 
spare the proteins, thus maintaining the nitrogen balance, or 
equilibrium, with smaller quantities of albuminoids. The best sources 
of carbohydrates are potatoes, cereals — like oatmeal, rice, etc., which 
may be taken with milk or cream — pastries, and above all, bread. 
Cane sugar and maple sugar, which enter into various culinary prepara- 
tions, are of great value. Daremberg, 1 however, objects to excessive 
consumption of sweets by consumptives because they are usually 
dyspeptics who do not stand it very well. He says that those who 
can take an excessive quantity of sugar may become fat rapidly; 
but this fattening is not lasting, just as the fattening obtained from 
an excessive milk diet. The best fattening is obtained from a mixed 
diet. However, there is no reason against eating sweet desserts, or 
even candies, in moderate quantities, provided they are taken after meals. 

Salts. — Mineral salts must not be neglected Even if the theory of 
demineralization is not well founded, there is no question that the 
loss of mineral salts is higher in consumptives than in healthy 
individuals. Iron, lime, soda, magnesia, and the phosphates are best 
supplied by such foods as bread, flour, oatmeal, rice, sago, tapioca, 
fresh vegetables, and fruits. All these may be given plain, or, better 
still, in various other culinary preparations. 

Condiments. — For their local appetizing effects, condiments, acting 
as they do as great salivary and gastric stimulants, may be taken, 
especially by those who suffer from anorexia. Some condiments, like 
mustard and garlic, contain allyl which assists in the digestion of fats, 
and is said to be bactericidal in the intestinal tract. At one time 
garlic was considered a good remedy against tuberculosis. Its active 
principle, allyl, was even administered subcutaneously. 

Dangers of Overfeeding. — While the majority of patients stand a 
moderate increase in the quantity of food fairly well, there are many 
who are decidedly harmed by it. This is especially seen in those who 
have been unreasonably induced to increase the quantity of protein 
foods, such as eggs, meat, etc., thus imposing an excessive and often 
dangerous burden upon the liver, kidneys, etc. In some cases we find 
that these organs have been decidedly crippled by such a diet. 

The symptoms produced by excessive protein consumption are 
unmistakable : The patient is drowsy for an hour or two after meals, 
has headache, and is irritable. At night he is restless and sleepless, 
or his sleep is disturbed by frightful dreams. The abdomen is dis- 

1 Les differentes formes cliniques de la tuberculose pulmonaire, Paris, 1905, p. 157. 



DIETARIES 619 

tended, the liver enlarged, and may be tender on palpation, and he 
has heartburn. Anorexia, bilious vomiting, and diarrhea are often 
seen. Cardiac palpitation and nightsweats are, at times, due to the 
indigestion thus induced. Because of the plethoric condition, the 
patients often have epistaxis and also hemorrhoids which contribute 
to their misery. The urine contains albumin, biliary pigments, 
indican, and glycosuria is not rare. Arthralgic pains in the joints are 
often the result of superalimentation. Older clinicians, believing 
that there exists an antagonism between the gouty and phthisical 
diatheses, urged excessive nitrogenous diet combined with wines, 
with a view of inducing sclerotic changes in the diseased lungs. On a 
similar principle, the excessive consumption of alcohol was advised 
in former days. The acneiform eruptions on the skin of some tuber- 
culous patients are very frequently due to the excessive protein foods 
which they consume. 

When overfeeding a patient we must watch out for the following 
danger signals: Failure of appetite, and symptoms of flatulent dys- 
pepsia; dyspnea on exertion which is obviously not due to the tuber- 
culous toxemia or the lung lesion; diarrhea, and at times vomiting. 
If these symptoms are not heeded and forced feeding is continued, 
irreparable damage may be done, the sheet-anchor of the patient, 
his power to digest food, is damaged, and his chances of recovery are 
materially lessened. But this should not deter us from trying to feed 
the tuberculous patient generously. "Excessive feeding is clearly a 
vastly better method of treatment than underfeeding, for it at least 
ensures the consumptive taking enough to repair his waste and to 
restore his normal power of resistance and recuperation," say Bards- 
well and Chapman, 1 " The point to realize is, that it is quite an unneces- 
sary hardship for patients to be overfed, and that it may do positive 
harm." 

When these harmful results of unwise feeding are borne in mind, 
unfortunate patients will not be forced to ingest large quantities of 
food which may be excessive and dangerous to healthy persons. Espe- 
cially careful must we be with plethoric, obese, and sedentary con- 
sumptives. A dilated stomach which does not empty itself with ease 
and promptness is particularly to be spared. The dangers of excessive 
fat consumption have already been dwelt upon. 

Dietaries. — From what has been said it is obvious that it is not 
necessary to give detailed dietaries for consumptives. When we aim 
at variety as the first requirement for a good diet, it would beneces- 
sary to give at least thirty menus to suit the average case. We will, 
therefore, merely mention some of the foods which may be utilized in 
attempts at feeding phthisical patients properly. It will be noted 
that they may eat nearly everything a healthy person can, so long as 
their malady is not complicated by conditions which alter matters. 

1 Diets in Tuberculosis, London, 1908, p. 49. 



620 DIETETIC TREATMENT 

Breakfast. — Milk, coffee, chocolate, cocoa, or tea. Bread, butter, 
cream, eggs, bacon, ham, ox tongue, fish (fresh or canned), fruits of 
any kind. Plenty of butter. Cereals of any kind. 

Lunch. — Fish, or entree; meats (roasts, chops, steaks, etc.), poultry, 
vegetables, custards, puddings, . cheese, milk, coffee, fruit. 

Dinner. — Soups, meats, poultry, game, fish, all vegetables, puddings, 
pastries, etc., cheese, ice cream, coffee, milk or chocolate. 

Without going into details of the various dishes that may be prepared 
by a good cook who knows the likes and dislikes of the patient, it can 
be stated that there is no dish which is contra-indicated in uncom- 
plicated phthisis. A good cook can do more for the 'patient than all 
the dietaries which may be printed in a book. 

Between the three main meals there may be allowed a light luncheon 
consisting of a glass of milk and some biscuit. Some are allowed an 
egg or two at that time, made in some form of punch, or in any style, 
provided it is well borne. Similarly, at about 4 p.m., tea, coffee, or 
milk may be allowed with some biscuit, etc. At night before retiring, 
a cup of milk with some crackers is beneficial for some patients. It 
will be noted that in this manner the patient may have his milk — 
about one-half to one quart per day — mainly outside of his meal-time, 
as drinks. 

It must be emphasized again that these foods should be palatably 
prepared and rendered digestible by proper cooking. Otherwise 
trouble may arise. The quantity to be ingested depends on the per- 
sonal equation of the patient, although in some cases matters may 
be forced for some time when indicated, but this should only be 
done bearing in mind the contra-indications which have already 
been discussed. 



CHAPTER XXXIX. 
MEDICINAL TREATMENT. 

Importance of Medicinal Treatment. — The disrepute of medicinal 
substances in phthisis during recent years is due to several causes. The 
first and most important is that we have no specific botanical, chem- 
ical, or physical agent which, when administered to a consumptive, 
will exert a selective action on the tubercle bacilli, as mercury and 
salvarsan do on the spirocheta of syphilis, and quinine on the malarial 
parasite. Nor have we a therapeutic agent which will enhance the 
resistance of the tissues against the ravages of the tubercle bacilli, 
or neutralize their poisons, or stimulate sclerosis of the affected area. 
But here we are in about the same position as when dealing with 
anemia, typhoid, pneumonia, rheumatism, etc. When we find that the 
salicylates relieve the more painful symptoms of rheumatism, and 
that iron increases the hemoglobin content of the erythrocytes in chlo- 
rosis, that digitalis increases the force of the cardiac muscle, we use 
these drugs although we know that digitalis does not regenerate 
destroyed heart valves, and salicylates do not remove the essential 
cause of acute articular rheumatism. Similarly if we find that creosote, 
arsenic, ichthyol, etc., have a beneficial influence on some of the annoy- 
ing clinical phenomena of phthisis, though they do not cure the disease, 
we must not discard them merely because they do not remove the 
cause of tuberculosis, or kill the bacilli within the body, or neutralize 
the tuberculous poisons, etc. 

There is another aspect to be considered in this connection. Except- 
ing the chosen few, who have sufficient means to pay for first-class 
sanatorium treatment, and inclination to remain in the institution for 
months and perhaps years, the bulk of the patients must be treated 
in their homes. Even if they get a few months of sanatorium treat- 
ment in a public institution, they must be treated in dispensaries, 
or by their family physicians, before admission, and after discharge. 
The patient is a human being; and when we consider the human 
element we find that, as a rule, he has no confidence in a physician 
who has no remedy for his ailment. The dictum "plenty of fresh 
air, milk, and eggs," he believes he knows as well as the physician. 
If his medical adviser will not prescribe for him, he will seek remedies 
from another who is more obliging in this respect, or from an advertis- 
ing quack. This is not only true of the ignorant, but also, almost to 
the same extent, of the supposedly intelligent patient. 

It cannot be denied that in many respects medicaments, properly 
administered, act by psychic suggestion. But so do the minute and 
detailed directions given, often in writing, about diet, rest, exercise, 



622 MEDICINAL TREATMENT 

sleep, etc., in institutions. "Medicinal agents," says G. Ktiss, 1 one 
of the most ardent advocates of tuberculin treatment in France, 
"no matter in what they consist, always inspire confidence in the 
physician; without them he is helpless. Moreover, by giving the 
patient, in addition to other treatment, a prescription calling for some 
medicine, we may succeed better in our attempts at keeping him 
away from the alluring advertisements of charlatans who very often 
impose on him." 

Harmless Medication. — The reasons why medicinal agents have 
fallen into disrepute in medical literature — by no means in the practice 
of the vast majority of physicians — are manifold. But the most 
important is perhaps the fact that drugs have been abused. "I regard 
medication as indispensable in the treatment of tuberculosis," says 
Renon. 2 "It has an undoubted good effect on the disease in general 
and an enormous psychic effect. But there is one important condi- 
tion which must be realized above all when giving drugs to consump- 
tives — they must be harmless" He illustrates this point by the fol- 
lowing instance : Some years ago the acetate of thallium was suggested 
as an excellent remedy against the nightsweats of phthisis, and a trial 
showed that it did control this symptom very well indeed. But it 
also had another effect: It caused the hair to fall out, and the nails 
to shed. The patients stopped sweating, but incidentally lost their 
hair and nails, which was a good reason for resentment. That certain 
drugs used in phthisiotherapy may have disastrous effects in addition 
to their influence on the disease, or some of its symptoms, must always 
be borne in mind. In fact, it has been stated with considerable truth 
that 50 per cent, of the dyspepsia in phthisical patients is due to 
improper medication. 

"False Specifics." — It is absurd to banish drugs from the arma- 
mentarium of the physician because they are "false specifics." As 
if true specifics are plentiful in other diseases. It is curious that 
those who label creosote, arsenic, and the iodides as false specifics, 
and urge specific treatment in the form of tuberculin, are in one 
breath stating that a specific remedy is yet to be found. "The wanton 
theory that you can treat with medicines and cure a pneumonia and 
typhoid fever," says Abraham Jacobi, 3 "but not a case of tubercu- 
losis, has taken possession of the oracular mind of the Colorado- 
ridden exile doctor. He should know better and do better. There 
is a drug treatment for tuberculosis, as for other diseases, and he 
should be glad to avail himself of it. There is no panacea, however, 
for tuberculosis, as there is none for pneumonia, or typhoid fever. 
But there are indications, and improvements of condition, and pro- 
longation of life and recoveries." 

Creosote. — There are very few sufferers from tuberculosis who have 
not been given creosote at some period of their illness. Its history is 

1 Gilbert and Carnot's Therapeutique, xxi, 594. 

2 Le traitement pratique de la tuberculose, Paris, 1908, p. 110. 

3 American Medicine, 1905, x, 1063. 



CREOSOTE 623 

similar to that of tuberculin. Introduced by Reichenbach, in 1830, 
it was given in very large doses, resulting in considerable harm to the 
patients. It was discarded for this reason, to be reintroduced some 
twenty-five years ago, and ever since it has held its place in the arma- 
mentarium of the physician in general and special practice. Its most 
ardent advocates do not consider it a specific, but then those urging 
tuberculin are still looking for a specific for tuberculosis. In the hands 
of those who have administered it intelligently it has proved the best 
medicinal agent to relieve some of the most baneful symptoms of the 
disease. 

When administered in the proper cases, and in proper dosage, it 
improves the appetite, stimulates digestion and assimilation, improves 
nutrition, diminishes expectoration, removing, at times, its purulent 
character and disagreeable taste and odor, all of which are sufficient 
encouragement to the average sufferer from phthisis to bestow con- 
fidence in the physician, and to look forward to an ultimate recovery. 
This beneficial action of creosote is ascribed by some authors to its 
power to inhibit the growth of, or destroy, tubercle bacilli in the gastro- 
intestinal tract, which are inevitably swallowed by every consumptive. 
It is one of the best gastric and intestinal antiseptics we have. It 
has been found that part of the ingested drug is excreted by the 
bronchial mucous membrane and, while it cannot be expected to 
destroy the bacilli in the lungs — hardly any drug could reach the 
avascular tubercle, even if it could be given in sufficiently large doses — 
it exerts there a beneficial influence, as is evidenced by the decrease 
in the amount of sputum brought out, and the diminution in the 
intensity of the associated bronchitis, laryngitis, and tracheitis. 

It is a peculiar fact, not generally appreciated, that creosote often 
provokes general and local reactions which are analogous to those 
provoked by tuberculin. Usually with excessive doses, but occasion- 
ally also with minimal doses, after taking creosote for several days 
the patient is overtaken by a feeling of chilliness and fever, pain in 
limbs, back, and joints, weakness, fatigue, and insomnia. Malaise, 
gastric disturbances and even vomiting in patients whose stomachs 
have heretofore not given any trouble, now make their appearance. 
The part of the creosote eliminated through the bronchial mucous 
membrane often excites a focal reaction which, at times, remainds one 
of the focal reaction of tuberculin. Of course, in the case of tuberculin 
a single dose is often enough to produce this reaction, while in the 
case of creosote it is only the more or less prolonged administration 
that is apt to produce this effect. In such cases sanguineous expectora- 
tion and even hemorrhage are not uncommon, while the lesion in the 
lung may be aggravated or even spread. Rales, which were previously 
absent or scanty, now make their appearance and the general aspect 
of the patient is aggravated. 

If the administration of creosote is persisted in after these symp- 
toms, as I have seen many times, the condition of the patient may be 
aggravated to an extent as to render the prognosis hopeless in a case 



624 MEDICINAL TREATMENT 

that previously had a fair outlook. Smoky urine, like that of phenol 
poisoning, is now seen; the patient complains of a taste of creosote in 
his mouth. This may be followed by vertigo, profuse perspiration, 
chilly sensations, and even cyanosis and collapse, as I have seen in 
one case which was greatly relieved by the discontinuance of the drug. 

Contra-indications. — Bearing all this in mind we can say that creosote 
is contra-indicated in all cases in tvhich it provokes gastric disturb- 
ances. If after taking moderate doses of the drug the appetite does 
not improve, it should be discontinued. It is also contra-indicated 
in all febrile cases in which the temperature is 100° F. or more, and 
also in all progressive cases, because thev are the ones in which general 
and local reactions are apt to be provoked and spread the lesion in 
the lungs. 

Patients subject to hemoptysis must not be given any creosote; even 
blood-streaked sputum should serve as a warning for the immediate 
discontinuance of the drug. Moreover, one must not wait for the 
appearance of smoky urine, but carefully watch for albumin which is 
often brought about by creosote. In general, albuminuria is a strong 
contra-indication to the administration of creosote. 

Indications. — In all incipient cases in which the appetite is poor and 
digestion defective, creosote may be given. With the improvement 
in the nutrition of the patient, owing to cessation of gastric and 
intestinal fermentation, the local condition in the lungs also shows 
improvement. In chronic, sluggish, afebrile cases of tuberculosis, 
especially those characterized by profuse expectoration, creosote is often 
of immense benefit, if rationally administered. In addition to its 
good effects on the gastro-intestinal functions, it also diminishes the 
amount of expectoration, ameliorates the cough, etc., and with the 
gain in weight and comfort, it has an excellent effect on the psychic 
state of the patient, who becomes more encouraged and hopeful. In 
fibroid phthisis, characterized by profuse expectoration of purulent 
material, provided there is no concomitant emphysema, creosote is 
the best remedy we have. I have seen drying up of cavities, at least 
temporarily, in some measure due to the proper administration of 
creosote. 

Administration. — A good product must be used. Soon after its 
introduction creosote fell into disuse mainly because of the bad quality 
of the product. Good creosote, fit for therapeutic administration, 
must be obtained from the fractional distillation of beech-wood tar, 
The product dispensed in many pharmacies in this country is obtained 
from the distillation of bituminous coal and contains many impurities 
which are not well tolerated. A good preparation of creosote contains 
25 per cent, of guaiacol, but many of the products dispensed under 
this name, even when obtained from beech-wood, contain much less. 

It is best administered in capsules which do away with the dis- 
agreeable odor. Moreover, the mucous membrane of the stomach and 
intestines is not so easily injured by creosote as that of the mouth and 
pharynx, so that the disagreeable local effects are done away with 



CREOSOTE 625 

through capsules. Some mix it with balsam of tolu, and it is best 
given after meals. Those who cannot swallow capsules may take it 
in this form: 

3— Creosoti gt t. xxx 2 

Vinipepsini 5i v 120 .o 

M. S — Teaspoonful in water three times a day after meals, gradually increasing. 

1$ — Creosoti, 

Picis liquidae radicis aa gr. xxiv 1 5 

Alcoholis absol 5iij 12.0 

Balsam, peruv 5i v 15 q 

Tinct. Helianthi annui g v 200 

Olei terebinth, rectificati, 

Myrtholi aa 3ij 7.5 

M. S. — Three times a day, one teaspoonful in milk or water one hour after meals. 

3— Tannini 3v 20.0 

Calcii phosphorici 5v 20.0 

Creosoti 3iiss 10.0 

M. — Div. in part 40; ft. capsul. 

S. — One capsule three times a day after meals. 

Beverley Robinson has had good results with the following : 

3 — Creosoti gtt. vj - 0.5 

Glycerini §j 25.0 

Spiritus frumenti ad 5iij 100.0 

M. S. — Teaspoonful in water three times a day after meals. 

This dose may be increased to two or three teaspoonfuls, or, if it is 
desired to increase the creosote, the amount of it may be doubled. 
If the whisky is deemed inadvisable, elixir calisaya or the compound 
tincture of cardamom may be substituted. 

Many have administered creosote by inhalation and have obtained 
good results. In this country, Beverley Robinson introduced this 
method. He recommends equal parts of creosote and alcohol or, when 
there is much irritative cough, equal parts of creosote, alcohol, and 
spirits of chloroform, on the sponge of a perforated zinc inhaler. The 
inhaler should be used frequently, at first for a few minutes, later 
gradually increasing the time until it is used from half an hour to an 
hour at a time, and finallv it may be used almost continually during 
the day and frequently all night. "These inhalations modify sputum 
favorably, diminish its quantity, lessen cough, thus promoting rest, 
sleep, and nutrition and general improvement physicially, and in some 
instances appear to be the means through which the patient has gotten 
rid of tubercle bacilli permanently." 

The following are good formula for inhalation : 

3— Creosoti gtt- vij 0.5 

Tincturae benzoini comp 5iij 100.0 

M. S. — To inhale a teaspoonful from boiling water, three or four times a day; shake. 

I*— Creosoti gtt. vij 0.5 

Olei pini silvestris 3hss 10.0 

Olei terebinthinse 3jss 5.0 

Tincturae benzoini Comp §iv 100.0 

M. S.— Shake. To inhale a teaspoonful from boiling water, three or four times a day. 
40 



626 MEDICINAL TREATMENT 

Derivatives of Creosote. — Because of its caustic taste, and disagree- 
able odor, creosote is not well tolerated by many patients; even when 
given in capsules the odor is often penetrating. Guaiacol, the main 
active principle of creosote, can be given instead, but it is insoluble 
in water, has an objectionable odor and taste and is a gastric irritant. 
There have been brought out a large number of preparations which 
retain most, or all, of the useful qualities of creosote without its draw- 
backs. These derivatives of creosote are mostly used at present 
with the same result as with the original drug. 

Of these creosote carbonate (creosotal) is perhaps the best. When 
ingested it breaks up slowly in the intestine, liberating creosote. It 
may be given in capsules of 5 to 10 drops three or four times a day. 
Many pharmaceutical houses market globules which are very elegant. 
It may also be given to patients to be taken in a certain number of 
drops in water, milk, or coffee; or the following prescription is useful: 

I^ — Creosoti carbonatis §iv 120.0 

Aetheris 3iss 5.0 

Alcoholis sol 3vj 25.0 

Vanilin gtt. vij 0.5 

M. S. — Fifteen drops in water or in milk three times a day after meals; increased if 
well tolerated. 

In many cases between 30 and 60 grains of creosote carbonate may 
be given per day. Guaiacol carbonate (duotal) is another preparation 
which is very extensively used. It may be given in powder or capsule 
from 10 to 40 grains a day, or combined with arsenic. 

Both of the above preparations are now sold quite reasonably. 
But for those who can afford to pay, we have a wider range of choice. 
Styracol (guaiacol cinnamate) contains a high percentage of guaiacol. 
Thiocol (potassium-guaiacol-sulphonate) may be given in 5 to 15 
grains three times a day in powder, tablet, or capsule. It is a non- 
toxic, tasteless, odorless powder, soluble in water. Many patients 
who do not tolerate guaiacol take this preparation very well, and in 
those who suffer from diarrhea it is to be preferred. But it contains 
less guaiacol than most other preparations of this class and its action 
is not so intense as that of the others. In fact, it is sometimes not 
decomposed in the intestines, and may be excreted unchanged. For 
those who prefer their medicine in liquid form and for children-, it may 
be given in the form of sirolin, a 10 per cent, solution of thiocol in 
orange syrup, which may be given one to three teaspoonfuls three 
times a day. There is no doubt that many who cannot tolerate 
creosote or guaiacol take this less toxic preparation very well. 

Sir R. Douglas Powell recommends the following: 

1$ — Guaiacol carbonatis, guaiacol benzoatis vel styracol 5iss 6.0 

Galcii hypophosphatis . . . . . . . . 5ss 2.0 

Pulvis tragacanthae co 3J 4.0 

Misce bene, adde guttatim: 

Syr. pruni virginianae vel elixir aurantii 3ss 16.0 
Syr. calcii lactophosphatis vel syr. hypophos- 

phitum co 5J 32.0 

Aquae chloroformi ad §vj 190.0 

S. — One teaspoonfuHn water or liquid malt three times a day soon after meals. 



ICHTHYOL 627 

1$ — Creosoti carbonatis *j v 16 

Tinct. gentianae co 3i v 16 

Syr. pruni virginianae . . . giii 90 

S.— One teaspoonful in a wineglass of water or malt extract after meals three times a 
day. Increase the dose by five drops each second day up to two teaspoonfuls by measure. 

Ichthyol.— Ammonium sulphoichthyolate or ichthyol has been found 
very useful in many cases of phthisis. Some authors state that it has 
a favorable influence on the metabolism, prevents albuminous decom- 
position and favors assimilation of food. Helmers found that about 
one-third of the sulphur ingested with ichthyol circulates in the 
juices of the body; others asserted that it even had a bactericidal 
action, without hurting the body cells, etc. It may, however, be stated 
that we do not know the exact pharmacology of this preparation, but 
that empirically it has been found useful in many cases of phthisis. 

It may be given in water 2 to 5 drops three times a day, beginning 
with the smaller dose and gradually increasing according to tolerance. 
Because of its disagreeable odor and taste, the drops should be diluted 
in large quantities of water or milk and given before meals. It may 
also be administered in black coffee. Or the following formulae may 
be used : 

3— Ichthyolis 3vj 25.0 

Aquae distil gij 60.0 

Alcoholis rectific gij 60.0 

Syr. citr., 

Syr. aurant cort aa giss 50.0 

M. S. — Teaspoonful in water three times a day before meals. 

De Renzi says that the above formula conceals the taste and odor 
of ichthyol. The following is also of use: 

3— Ichthyolis 3iiss 10.0 

Syrup, simpl 3v 20.0 

Aquae menth. piper giij 80.0 

M. S. — Teaspoonful in a glass of water three times a day. 

In many cases ichthyol improves the appetite, diminishes the fre- 
quency of the cough and the expectoration, changing the latter so that 
its purulent character vanishes. The general condition of the patient 
improves with the improvement in the nutrition. In some patients 
the remedy disagrees, causing flatulence, abdominal pains, diarrhea, 
loss of appetite, and eructation of gases. In fact, as has been shown 
by Barnes, in patients in whom the administration of ichthyol does 
not immediately improve the appetite, it is not advisable to continue 
the drug. I can add that diarrhea also shows that the drug disagrees. 
My patients do not, as a rule, mind the disagreeable odor and taste 
when given well diluted with water, milk, or coffee. 

Ichthyol should be tried in every case of phthisis because it has 
not the dangerous characters of creosote and arsenic and their deriva- 
tives ; in fact, it is well tolerated in most cases, only gastro-intestinal 
disturbances occasionally preventing its use. 



628 MEDICINAL TREATMENT 

Arsenic. — For centuries arsenic has been used by physicians in the 
treatment of tuberculosis. As has been pointed out by A. Arkin and 
H. J. Corper, 1 Dioscorides employed it internally and by inhalation. 
Antylus, who lived in the third century A.n., Marcellus Empyricus, 
and Galen all recommended it and described cures from the inhalation 
of powdered arsenic. The Chinese and the Hindus also found it useful 
in tuberculosis. Empirically, it has also been employed by modern 
physicians in various forms, and many report excellent results. While 
some claimed that it has a direct action on the tubercle bacilli, recent 
careful investigations by Arkin and Corper have shown that this is 
not the case. Many preparations of arsenic — sodium arsenite, sodium 
cacodylate, mercury cacodylate, atoxyl, arsacetin, and neosalvarsan 
have all been found without any action on tubercle bacilli in vitro. 
Administered to tuberculous animals parenterally these preparations 
of arsenic were subsequently found in the liver, lungs, kidneys, blood, 
spleen, and tuberculous tissues (lymph glands of guinea-pigs and eye 
of rabbit), the concentrations in all these tissues not greatly differing. 
No evidence of accumulation in the tuberculous tissues was obtained. 

Clinical experience has, however, shown that arsenic is an excellent 
stimulant of nutrition, a hematinic, reconstructive, and alterative in 
chronic wasting diseases, including phthisis. The various organic 
arsenic compounds recently introduced were stated to lack the greater 
part of the toxicity of arsenic, while retaining its curative, reconstruc- 
tive, and antiseptic properties. The advocates of arsenic medication 
in tuberculosis claim that it increases the appetite, improves assimila- 
tion of food, and stimulates the blood-forming organs, .in addition to 
its stimulating effects on the nervous system. In short, arsenic is sup- 
posed to fortify the tissues against the ravages of the tubercle bacilli. 

From an extensive use of arsenic in phthisis the author has not 
found that it exerts any direct influence on the tuberculous lesion in 
the lungs, even when administered to patients who tolerate it. The 
quantity and quality of the expectoration are, however, very favor- 
ably influenced; purulent sputum often becoming mucous and greatly 
reduced in quantity. With the improvement in the appetite and 
nutrition a great deal is gained — the patient is encouraged. The fever 
is, however, not influenced, nor are the nightsweats. In fact, it should 
not be given to febrile patients. 

It may be given as an adjuvant to creosote treatment in the form 
of trioxide, as in the following formula: 

]$ — Guaiacolis carbonatis 3v 20.0 

Arsenici trioxidi gr. iss 0.1 

Strychninse sulphatis gr. j . 06 

M. ft. pilulae no. lx div. 

S. — One pill three times a day after meals. 

It may be given in the form of Fowler's solution, beginning with 2 
or 3 drops after meals and increasing daily until 10 drops are taken 
three times a day. 

i Jour. Infect. Dis., 1916, xviii, 335. 



IODIN 629 

During recent years various organic compounds of arsenic have beer 
used in phthisis, administered either by mouth or hypodermically. 
Of these the cacodylates of sodium, strychnin, iron, and guaiacol may 
be mentioned. Many of these, as well as atoxyl, are at present sold 
by pharmaceutical houses in ampoules ready for hypodermic and 
intravenous administration. But in my experience none of these 
preparations has any advantages over the inorganic arsenic; the 
trioxide, and Fowler's solution, answer all requirements. In fact, some 
of them, notably atoxyl, are dangerous because they are liable to 
cause amblyopia. 

When administering arsenic to phthisical patients certain precau- 
tions are to be taken. It should not be continued, especially in large 
doses, for more than a week or ten days. Symptoms of intolerance 
may make their appearance, such as loss of appetite, thirst and dryness 
in the mouth, colicky pains, and diarrhea. In some cases the fever 
rises as a result of large or even small doses of arsenic. Tachycardia, 
cardiac palpitation, and insomnia are occasionally observed. It should 
not be given to febrile patients, and to those showing a tendency to 
hemoptysis. In fact, if during the administration of "arsenic there 
appears streaky sputum, it should be considered a danger signal and 
the arsenic is to be discontinued at once. 

Iodin. — For generations iodin has been used in the treatment of 
scrofulous children with good results. It has also been found useful 
in assisting the resolution of pleural adhesions, and in the relief of the 
symptoms of chronic bronchitis, pulmonary emphysema, and asthma. 
That the iodides have an effect on tuberculous lesions in the lungs is 
evidenced by the fact that small doses of the iodide of potassium 
may cause, in persons with incipient tuberculosis, reactions similar 
to those produced by tuberculin, as was shown by Rondot. In fact, 
many authors recommend it for diagnostic purposes, at least to pro- 
voke expectoration which may be examined for tubercle bacilli. Sorel 1 
found that tuberculous animals, when given large doses of potassium 
iodide, succumb to generalized miliary tuberculosis, and usually much 
earlier than the controls. 

Recent investigations tend to show that iodin counteracts and 
inhibits the lipoid element in the tubercle bacilli. Joblins and Petersen 
found that soaps of the unsaturated fatty acids were capable of inhibit- 
ing the action of trypsin and other ferments, and, moreover, they 
discovered in the tubercle bacilli a ferment inhibiting substance of the 
nature of a lipoid, to which they attribute the lack of autolysis and 
consequent caseation in tuberculosis. They found that the higher 
the iodin value of a soap the less was its activity as an inhibiting 
agent, while saturation with iodin would destroy entirely its inhibiting 
powers. They also found that ether-soluble substances of the bacilli, 
which constitute 25 to 35 per cent, of their weight, and which are 

1 Ann. de l'Inst. Pasteur, 1909, xxiii, 533. 



630 MEDICINAL TREATMENT 

largely composed of fatty acids, have a marked restraining action 
on trypsin. It is thus suggested by E. Curtin that iodin acts in tuber- 
culosis by saturating the unsaturated bonds of the fatty acids of the 
lipoids, rendering the substituted product less active as an anti- 
tryptic agent. 

Some French authors recommend the iodides in most cases of pul- 
monary tuberculosis, but it seems to be a dangerous drug for the 
reasons just stated. But in some cases of incipient phthisis without 
fever the iodides do good, especially in those in whom the tuberculous 
process has been implanted on emphysematous lungs. This is also 
true of asthma and tuberculosis — the iodides often control or relieve 
the nocturnal attacks of dyspnea. But one must always guard against 
giving this drug to sufferers from the congestive, inflammatory, pro- 
gressive lesions, and those subject to -hemoptysis. 

It is best given in a saturated solution of iodide of potassium of which 
each drop represents 1 grain of the drug. Small doses are to be given 
at first, 2 to 5 grains, three to five times a day. If no intolerance is 
shown it may be increased. I have often used some of the organic 
compounds of iodin — sajodin, etc. — with good results. 

A better way of administering iodin is giving the pharmacopeal 
tincture in increasing doses, beginning with one drop well diluted 
in water or milk, three times a day, and increasing daily by one drop, 
until twenty or even thirty drops are given daily, or until toleration 
is reached. Some patients show symptoms of iodism very soon, and 
the dose must be reduced, but in the majority of cases large doses may 
thus be given for a long period with very marked results. In fibroid 
phthisis it has often proved invaluable. 

Succinimide of Mercury. — Mercury has been used in the treatment 
of tuberculosis for many years. But more recently Dr. B. L. Wright 
developed a new method of administering it and reported a larger 
number of recoveries than has been claimed with any other medica- 
tion. He used the succinimide of mercury hypodermically, in doses 
of J of a grain given on alternate days, increasing the dose guardedly 
until the limits of toleration are reached. As soon as symptoms of 
mercurialization appear, or there is a rise in the temperature, anorexia, 
loss in weight, etc., the dose is either reduced or the treatment is dis- 
continued for a time. In most cases about thirty injections are given, 
followed by a rest of two weeks, during which period iodide of potas- 
sium may be administered. A second series of injections is given to 
those who tolerate the drug. 

I have tried this treatment and found it of immense value in 
phthisis complicating syphilis; otherwise it is decidedly harmful. As 
was already stated, it appears that when tuberculosis is implanted in 
a syphilitic subject, the disease is apt to run a very sluggish, chronic 
course. Fibrosis is very active. In these cases both the iodides and 
mercury, if intelligently and guardedly administered, may be very 
efficacious. The succinimide of mercury may be used instead of 



COD-LIVER OIL 631 

other forms of the drug. But the doses given by Wright are decidedly 
excessive — the same results may be obtained by the hypodermic 
administration of \ or T V of a grain twice weekly. On the other 
hand, salvarsan now offers a better means of combating active syphilis 
combined with tuberculosis than the succinimide of mercury. 

Hypophosphites and Glycerophosphates.— It will be noted that 
most of the medicinal preparations mentioned above have their indi- 
cations and contra-indications, and some are not without danger when 
improperly administered. The safest medication in phthisis appears 
to be the time-honored administration of the hypophosphites. Re- 
cently the glycerophosphates of lime, iron, magnesium, etc., have 
been used very extensively on the theory that phthisis is a manifes- 
tation of lime starvation and that recalcification and remineralization 
of the body are of great importance in our efforts at combating the 
effects of the tuberculous process. There is no doubt that in many 
cases of phthisis these medicinal substances have an excellent influence 
on the nutrition of the patient and they are also of use in relieving 
the anemia which is such a frequent accompaniment of the disease. 
We may give the official compound syrup of hypophosphites in doses 
of one to two teaspoonfuls three times a day after meals. The gly- 
cerophosphates may be given in any form. Pharmaceutical houses 
have many elegant and palatable preparations of glycerophosphates 
in tablet, capsule, and liquid forms which may be used. Their tonic 
effects are beyond question. 

Cod-liver Oil. — Physicians of past generations bestowed great 
confidence in the therapeutic virtues of cod-liver oil in tuberculosis, 
and many modern practitioners still consider it an excellent thera- 
peutic agent. Some have ascribed the curative action of this oil to 
certain of its constituents. Thus, some believe that it is the iodin 
which is effective, others see in the bromin the active principle. But 
careful chemical analysis has shown that there are only traces of these 
elements in cod-liver oil. The biliary salts, the hepatic ferments, 
the lipoids, the lecithin, etc., have been stated to be of more value 
than the fat of cod-liver oil. John W. Wells 1 and others believe that, 
in addition to the ready absorption of the fat of cod-liver oil, it pos- 
sesses powers of increasing the absorption of other fats of the food to 
a marked degree. 

The recent intensive studies of the internal secretions have also 
thrown some light on the action of cod-liver oil in phthisis, according 
to some authors. Thus, Williams 2 recently stated that the superiority 
of this oil to others is mainly due to the internal secretion of the liver 
of the fish, which "when introduced into the human economy, acts 
as a stimulant to one of the normal internal secretory glands, and 
the secretion of the one so stimulated is inimical to the development 
of the tubercle bacilli." He believes that only the crude oil contains 

» British Med. Jour., 1902, ii, 1222. 2 Practitioner, 1911, lxxxviii, 605. 



632 MEDICINAL TREATMENT 

these active principles and is therefore more efficacious than the 
refined oil. Iscovesco, 1 from his experimental researches, is con- 
vinced that the efficaciousness of cod-liver oil is due to the lecithides 
which it contains. He treated a large series of animals for four months. 
Those who got cod-liver oil increased in weight to the extent of 55 
per cent.; those who got cod-liver oil from which the lecithides had 
been removed gained only 27 per cent. ; those who were given olive 
oil gained 33 per cent.; others were given oil to which was added 0.5 
pro mille of the lecithides extracted from cod-liver oil and they gained 
56 per cent. The control animals gained only 29 per cent. Williams 
and Forsyth 2 claim that the unsaturated fatty avoids of cod-liver oil 
tend to disintegrate the waxy envelope of the tubercle bacilli, thus 
destroying them. 

These theories are interesting, and deserve further study, but there 
is no doubt that cod-liver oil is an important remedy in tuberculosis, 
even if only for the fact that it contains a considerable proportion of 
easily assimilable fat, and it may be used as a food rather than as a 
drug. Patients who do not take animal fats like butter, etc., are 
distinctly benefited by cod-liver oil. 

Cod-liver oil should be given in large doses; to some patients as 
much as 2 ounces per day may be given and some French authors, like 
Jaccound, Grancher, and Daremberg, have given more than 4 ounces 
per day. Some apparently have a marked tolerance for this prepara- 
tion, and they may utilize it instead of superalimentation. On the 
other hand, there are patients who cannot tolerate it, and even small 
doses cause eructations, nausea, and oily taste in the mouth. Diar- 
rhea is another of the untoward effects in some who do not bear the 
oil very well. 

Indications. — Cod-liver oil is indicated in all afebrile cases of phthisis. 
All patients who willingly take it and digest it well in large doses 
should be given this oil, without incidentally curtailing their usual 
amount of other nourishment. It may be continued for a long period 
of time; as long as the patient is apparently benefited by it and his 
digestive functions remain normal, the appetite is good and, above 
all, there is no diarrhea. Patients with fever do not tolerate it as 
well as those who have no pyrexia. Children with tendencies to 
scrofula, with enlarged tuberculous glands, especially tracheobronchial 
adenopathy, and who are as a result underfed and anemic, often 
derive great benefit from cod-liver oil. It appears that children take 
it with greater ease, and more often with distinct benefit, than adults. 

Contra-indications. — Cod-liver oil is contra-indicated in cases in 
which the patients do not tolerate it in even small doses. The best 
criteria are the state of the appetite and digestion. As soon as these 
are deranged, it should be discontinued. 

1 Compt. rend. Soc. de biol., 1914, lxxvi, 34. 

2 British Med. Jour., 1909, ii, 1120. 



COD-LIVER OIL 633 

Administration.— So long as we consider cod-liver oil merely a fat 
food, and disregard its other constituents, it is best to administer it 
in as palatable a form as possible. In former times the crude oil, a 
product of decomposition of the livers of the cod, was used. Some 
modern authors even now insist that this form is most beneficial for 
phthisical patients. But it has a very disagreeable odor and taste and 
it requires courage on the part of the patient to swallow it. It is also 
apt to cause indigestion, eructations, diarrhea, etc. The light, or 
amber-colored oil, prepared by melting fresh livers by a steam process, 
is less disagreeable and more easily tolerated. It should at first be 
given in small doses of the Norwegian, light-colored oil, and in case 
the gastro-intestinal tract tolerates it, the dose is to be increased so 
that within a few weeks the patient takes four to six tablespoonfuls 
a day after meals. It should not be forced on patients; when they 
refuse to take it, or it causes nausea, eructations, diarrhea, etc., it 
should be discontinued. 

It is best that the pure oil should be given and many patients take 
it easily. With some the odor and taste have to be masked, and this 
may be done in the following manner: It may be given in orange- 
juice, or in some volatile oil. Many patients take it with ease in coffee 
or milk. A pinch of salt placed in the mouth before taking it may dis- 
guise the taste. Those who are allowed to take alcohol may take 
some whisky or brandy into the mouth where it is kept for a few 
seconds without swallowing, and then the oil is taken. Some use 
peppermint-water or tomato ketchup for the purpose, or orange- or 
lemon-juice. The difficulties owing to the odor and taste are over- 
come soon in most patients, and they take it freely. 

The various emulsions offer no advantage over the pure oil. If 
they contain the indicated percentage of the oil, they are as dis- 
agreeable as the pure article, and one who can take an emulsion can 
take and digest the oil. The various preparations and "extracts" 
which are alleged to have all the therapeutic qualities of cod-liver 
oil without any of its disadvantages, have been found worthless, 
lacking as they do the fatty substances which are of value for the 
nutrition of the patient. On the other hand, many of the preparations 
of cod-liver oil and malt, hypophosphites, creosote, etc., may be 
utilized in the treatment of phthisis with advantage. It is, however, 
to be borne in mind that large doses are necessary to procure results, 
and that these preparations contain but a small proportion of cod- 
liver oil. 



CHAPTER XL. 
SPECIFIC TREATMENT. 

Strictly speaking, the term "specific" should only be applied to 
a remedy or preparation which has a proved selective curative effect 
on a certain disease. From this viewpoint we can state unequivo- 
cally that ice have no specific remedy for tuberculosis in any of its clin- 
ical forms. We have no substance, drug, or preparation which will 
cure, or remove, or ameliorate the symptoms in the vast majority of 
phthisical patients to the same degree as mercury or salvarsan is effica- 
cious in syphilis, quinine in malaria, or thyroid in myxedema. This 
is a fact which all thoughtful workers in the tuberculosis field acknowl- 
edge; even those who employ tuberculin extensively, and do not hesi- 
tate to call it specific treatment, say that it is only a good adjuvant 
to other therapeutic methods which should be tried in selected cases 
so long as a true specific is not available. Moreover, it appears that 
tuberculin only works in sanatoriums, where the patients are, in 
addition to the specific treatment, subjected to a rigorous hygienic 
and dietetic regime. It is distinctly stated that when the latter is 
lacking, tuberculin is of no avail. 

It appears that the only justification for the use of the term specific 
when speaking of tuberculin treatment is the fact that this word has 
recently received a wider application and is now also used to designate 
remedies which are especially indicated, and used, in any particular 
disease. 

The writer has given tuberculin therapy a fair trial in both his 
hospital and private practice and found it either altogether wanting 
in therapeutic effects when used in infinitesimally small doses, as is 
advised by most of its contemporary advocates, or decidedly harmful 
when given in substantial doses. This opinion is shared by most of 
those engaged in the treatment of tuberculosis, excepting such as 
have themselves discovered some tuberculin, or who are in charge 
of sanatoriums catering to well-to-do private patients. In the public 
sanatoriums in this country very little of tuberculin is used for thera- 
peutic purposes. The vast majority of patients in these institutions 
are cared -for by the old methods. It cannot be said that it is the 
cost which precludes the use of tuberculin in public institutions. 
Salvarsan is a really expensive drug but is used in all hospitals. 

Our reasons for discarding tuberculin from the therapeutic arma- 
mentarium are the following: 

The Variety of Tuberculins. — It is an old axiom in therapeutics 
that the larger the number of drugs recommended for any given disease, 
the less the chances of curing it with any of those mentioned as effica- 



THE VARIETY OF TUBERCULIXS 635 

cious. Thus, we have only to consult the index of any standard materia 
medica and count the number of remedies recommended for typhoid 
fever, pneumonia, nephritis, gastritis, etc., and to compare it with 
the number mentioned as effective in myxedema, malaria, syphilis, 
valvular heart disease, etc., to be convinced that the axiom holds 
good. The large number of tuberculins alone should give us a strong 
hint that none of them is a specific, or will surely cure. I counted in 
one recent book forty-six varieties of tuberculins, and I could add 
almost as many which the author has not mentioned. 

"We have no standard tuberculin," says William Charles White, 1 
himself an advocate of tuberculin, "and furthermore we have no 
manufacturer who prepares the same strength twice. Consequently 
the dose of one tuberculin is no more the dose of another tuberculin 
than the dose of a sherry glass is the dose of a champagne glass. We 
have no method of testing the strength of a given tuberculin unless 
it is the biological one, and this is tedious, if it has to be used for 
every patient for every new supply of tuberculin. If, however, the 
tuberculin standard is at fault, what a vastly greater difference exists 
in the physicians who administer it! There are almost as many 
methods of dosage and administration as there are administrators. 
Each physician believes his method the best. Some have no method 
at all." It appears that for practical purposes we have no methods 
to weigh or measure the toxicity of tuberculins. Two preparations 
made by the identical method may differ very much if they are 
derived from different cultures; especially do they vary with the 
age of the culture. 

All authors entitled to an opinion agree that the action of all tuber- 
culins is the same. The preparations differ only as regards their 
strength, toxicity, capacity for absorption, etc. But inasmuch as 
the active element or substance of tuberculin has not yet been isolated, 
nor can the strength of a given preparation be measured, it appears 
that the differences which are known to exist between the various 
forms of tuberculin cannot be definitely ascertained. Salvarsan, 
strychnin, morphin, digitalis, or tetanus and diphtheria antitoxin 
which could not be measured would hardly be used by medical men. 

In general it may be stated that there are three varieties or types 
of tuberculin : 

1. Old tuberculin, consisting of the exotoxin— a glycerin extract 
containing the soluble products of the tubercle bacilli in the medium 
in which they have grown, glycerin, bouillon, extractives, etc. Though 
it should be mentioned that most investigators are of the opinion that 
there is no tuberculous exotoxin. 

2. The new tuberculins, made up of the insoluble endoplasm of the 
bacilli and the poisons contained within them— endotoxins. 

3. Those which consist in a mixture of both the above forms. 

1 Tr. Fifth Annual Conference Nat. Assn. Prevent. Consumption, London, 1913, p. 70. 



636 SPECIFIC TREATMENT 

But when injected into the tuberculous human or animal body any 
tuberculin produces practically the same effect. On this nearly all 
agree, even those who maintain that only a certain variety of tuber- 
culin should be used if therapeutic results are to be obtained. 

Action of Tuberculin. — As was already stated (see p. 33), tuber- 
culin is harmless when injected into a non-tuberculous body, and pro- 
duces its toxic effects only in those who have suffered a tuberculous 
infection. But we do not know how it acts under these circumstances. 
Wolff-Eisner's tuberculolysin hypothesis is about the most plausible 
and the one accepted by most authors. But we have not as yet 
succeeded in isolating a specific tuberculous antibody, nor the tuber- 
culolysin from the serum of infected animals. 

At first sight it would appear that tuberculin is specific, considering 
that it acts only on infected organisms, but even this is not conclusive. 
It seems that the infected organism is not only hypersensitive to 
tuberculin, but to all foreign proteins. We can produce elevation of 
temperature, malaise, backache, nausea, etc., and even the local 
reaction, by the injection of any foreign protein into a tuberculous 
person. "Neither the local nor the general reaction is absolutely 
specific," says Baldwin, 1 himself using tuberculin extensively; "vari- 
ous nucleoproteins, yeast nuclein, bacterial proteids in general, and 
digestive products, such as albumoses, are capable of producing sim- 
ilar effects. Cinnamic acid, cantharidin, pilocarpin, and other alkaloids 
also act to some degree, although less as local irritants than general 
leukocyte stimulants." In my experience, potassium iodid and 
creosote, when given in large doses, may produce general and focal 
reactions not unlike those produced by tuberculin. 

All efforts at producing partial or complete immunity with the 
administration of tuberculin in man or animals have utterly failed. 
Even Sahli, who urges tuberculin treatment, says that "tuberculin 
treatment has not the character of a true immunization, though it 
produces immunizatory effects in the organism." 

That it is not necessarily the reaction which is effective thera- 
peutically is clear when we consider that modern tuberculin treat- 
ment aims at eliminating entirely these reactions by the administra- 
tion of infinitesimally small doses. The hope that the focal reactions, 
consisting in hyperemia at the site of the lesion, and the surrounding 
tissues, may promote the healing of the lesion, cannot be seriously 
entertained by clinicians. Usually when the focal reaction is intense, 
it cannot be controlled and the congestion often produces renewed 
activity of the diseased process. Quiescent foci, calcareous particles, 
are "sleeping dogs" and should not be disturbed, as Sir James K. 
Fowler 2 says. The establishment of tuberculin tolerance, which some 
strive at, is no proof of healing; in fact, it is usually short lived. More- 
over, the tuberculin reaction is a very complex process and varies 

1 Osier's Modern Medicine, i, 308. 

2 Tr. Annual Conference Nat. Assn. Prevent. Consumption, London, 1913, v, 93. 



LACK OF THERAPEUTIC EFFECTS OF TUBERCULIN 637 

with the preparation used, the individual treated and also with the 
time it is administered. One day the patient is tolerant, the other he 
is badly affected with even a minimal dose. 

There is no harm in administering most drugs in teaspoonfuls, 
tablespoonfuls, or measuring them with the point of a knife, as has been 
done for centuries. Patients have recovered with such inexact meas- 
ures, some may have been harmed, but lethal doses are rarely given 
in this manner. But we cannot give a potent agent like tuberculin 
to a patient who needs all the vital energy he has, and more, in this 
manner, any more than we can give with impunity strychnin, mor- 
phin, digitalis, salvarsan, etc., without exact dosage. So long as 
we cannot measure the toxicity of tuberculin, we cannot administer it 
rationally and prevent sudden and at times harmful, reactions which 
may appear when least expected. 

Experimental Evidence of the Lack of Therapeutic Effects of Tuber- 
culin. — Tuberculin as a therapeutic agent is based on results obtained 
in the laboratory through animal experimentation. It would be 
reasonable to exact that it should be efficacious in experimental tuber- 
culosis in animals. But it is a fact that there is no record in medical 
literature that any investigator has succeeded in curing or benefiting 
a tuberculous animal with tuberculin treatment. In Robert Koch's 
writings at the time he introduced tuberculin we can find no clear-cut 
statement to the effect that he cured an animal with this agent. 
Klimmer, Lydia Rabinowitsch, 1 and others have recently tried small, 
very small closes, corresponding to those used at present in the treat- 
ment of human phthisis, but the tuberculous guinea-pigs and rabbits 
failed to improve. "No curative influence has been exercised by the 
tuberculin . The control animals lived sometimes longer than the treated 
animals. On the use of large doses the animals readily succumbed." 

It has never been observed that the administration of tuberculin to 
tuberculous animals should promote healing of a tuberculous lesion, 
that cicatrization should be favored. 

What has been observed, however, is that very often dormant tuber- 
culous processes are activated after the administration of tuberculin. 
Bacilli which gave no trouble were released, "mobilized," producing a 
bacteremia, as was already mentioned (see p. 245.) 

Serologically, tuberculin has hardly ever shown its therapeutic 
value. Like other antigens, tuberculin stimulates the production of 
antibodies when inoculated into a tuberculous organism. But these 
antibodies cannot be considered true antituberculins because they do 
not neutralize tuberculin in vitro. We know that the antibodies pro- 
duced by other toxins, as those of tetanus and diphtheria, neutralize 
the toxins of these infections in vitro, while the tuberculous antibodies 
do nothing of the kind. We can consequently see no theoretical or 
practical value in tuberculin from this viewpoint. 

i Tr. Annual Conference Nat, Assn. Prevent, Consumption, London, 1913, p. 44. 



638 SPECIFIC TREATMENT 

Clinical Evidence. — In a discussion on the merits of tuberculin treat- 
ment, Hector W. G. Mackenzie 1 said that "he should like to ask 
whether anyone has been able to obtain a cure of tuberculous ulcer, 
arising from the primary inoculation by means of tuberculin injec- 
tions. He fears the answer must be in the negative." 

We arrive at the same conclusion when we consider the clinical 
evidence presented by the advocates of tuberculin treatment in phthisis. 
All effective medication has its indications, contra-indications, and 
limitations. True specific treatment is not free from these limita- 
tions, as is true of quinin, mercury, salvarsan, thyroid, etc. But the 
limitations in the range of usefulness of these drugs depend mainly, 
if not entirely, on the presence or absence of mixed infection, of pre- 
existing diseases, on the constitutional peculiarities of the patient, 
and complicating diseases. In a clear-cut case of syphilis in the 
average patient, salvarsan or mercury will produce evident curative 
effects; malarial fever will be abated by quinin, myxedema is relieved 
by thyroid, etc. But in the purest forms of' tuberculosis, in acute 
miliary tuberculosis, tuberculin is powerless, which fact alone should 
arouse suspicion as to its specific qualities. 

It appears to be a general rule in pathology, as has been pointed 
out by von Hansemann, 2 that diseases which are not at times spon- 
taneously cured cannot be cured by any known therapeutic measure. 
Rabies is usually mentioned as an exception, but even this may only 
be prevented; once it has developed, it cannot be cured. Specific 
therapeutics aims at curing diseases which are not known to be cured 
spontaneously. But it has never been observed that a patient suffer- 
ing from acute miliary tuberculosis should be cured, the few cases 
mentioned by Cornet are all very doubtful. Acute miliary tubercu- 
losis is the purest foon of the disease without mixed infection; the 
tubercle bacilli, though disseminated all over the body, are found in 
each place in small numbers and they do not produce avascular 
masses from which medication is excluded. It should be the crucial 
test for specific treatment. As a matter of fact, however, tuberculin 
is altogether powerless in acute miliary tuberculosis, as it is in all 
progressive cases of phthisis. 

Good results are reported by those who have used it in glandular, 
osseous, and articular tuberculosis in children. But we have already 
mentioned that these have a strong natural tendency to heal spon- 
taneously in the vast majority of cases (see p. 412). Even surgeons 
advise and practise conservative treatment. 

In phthisis the ideal cases are said to be those in the incipient stage 
of the disease. But when we recall that a really incipient case is one 
which has "slight or no constitutional symptoms, including particularly 
gastric or intestinal disturbances or rapid loss of weight; slight or no 
elevation of temperature or acceleration of pulse at any time during 

1 Tr. Annual Conference Nat. Assn. Prevent, Consumption, London, 1913, p. 9. 
? Berl. klin. Wchnschr., 1911, xlvii, 1, 



DOSAGE 639 

the twenty-four hours," we are not surprised that many recover with 
tuberculin treatment. It has been found recently that in Germany, 
France, and England many of those who were certified as tuber- 
culous and eligible for sanatoriums, were fit for military service. 
Instead of sending them to institutions, as has been the rule during 
times of peace, they were sent to the trenches and in the vast majority 
of cases they stood the hardships of war as well as other soldiers. 

The reasons for this anomaly are various. Blomel claims that 80 
per cent, of these cases were wrongly diagnosticated. But even such 
as showed the presence of tubercle bacilli in the sputum were found 
fit for military service. To my mind there are many cases of abortive 
tuberculosis which under ordinary circumstances pass as chronic 
phthisis and any form of treatment gets the credit for the cure. 
Tuberculin evidently gets its share of credit. 

Lack of Reliable Statistics of the Efficacy of Tuberculin. — To prove 
its therapeutic efficacy, a specific must produce results in a larger 
proportion of cases of phthisis than is observed with the older methods 
of treatment. This has not been shown. In fact, there are no reliable 
statistics of large series of cases available. In their book on tuber- 
culin treatment, Riviere and Morland state that they decided to 
give no statistics of results of tuberculin treatment because they 
consider figures of questionable value. Sahli also gives no statistics, 
while the figures compiled by Brown in Klebs's book show clearly that 
there is no difference in results between the group treated with 
as compared with that treated without tuberculin. Reliable statistics 
of ultimate results are not available at all. 

Dosage. — It would be pretty bad for physicians, and for patients, 
if there was such a disagreement as to the dose of any potent remedy, 
especially if it was not known which quantity of the remedy is likely 
to be harmful. The initial dose ranges between 1 mg., recommended 
by Bandelier and Ropke, to 0.0000005 mg., recommended by Philippi. 
Between these two extremes, various authors recommend intermediate 
quantities, each one claiming that his standard is best, or, what is of 
more importance, the safest. Still, with such uncertainty as to dosage, 
many authors make tables of dosage and iron-clad rules as to gradual 
increase in the dose, and the final dose, some using logarithmic tables 
for their calculations, as if they were dealing with an exact science. 

The fact is that there is no mystery about the technic of adminis- 
tration of tuberculin, and no knowledge of higher mathematics is 
necessary to make the various dilutions properly. Many pharmaceuti- 
cal houses sell tuberculin in proper dilutions ready for use. But those 
who want to make their own dilutions can do it easily. 

All that is necessary is six or ten amber-colored bottles of 10 or 20 
c.c. capacity each. They are to be clean and properly sterilized. A 
larger bottle containing the diluent (sterilized, or distilled water 
containing 0.8 per cent, of sodium chloride and 0.5 per cent. of. carbolic 
acid) should be at hand, Each of the small, colored bottles is to be 



640 SPECIFIC TREATMENT 

filled with 9 c.c. of the diluent and marked with numbers, I, II, III, 
IV, V, VI, etc., respectively. Now take 1 c.c. of tuberculin and drop 
it into bottle No. I and shake it well. It now contains a 10 per cent, 
solution of tuberculin, so that a syringeful, with a capacity of 1 c.c, 
contains 0.1 c.c. of tuberculin, or 100 c.mm. 

When we take 1 c.c. from bottle No. I and drop it into bottle No. 
II, we get a solution containing 1 per cent, of tuberculin; one syringe- 
ful contains 10 c.mm. of tuberculin. Repeating the process, dropping 
1 c.c. from bottle No. II into bottle No. Ill, the latter will contain 
a 1 to 1000 dilution; 1 c.c. equals 1 c.mm. of tuberculin; bottle No. 
IV, a 1 to 10,000 dilution; bottle No. V, a 1 to 100,000 dilution; 
and bottle No. VI, a 1 to 1,000,000 dilution, so that a syringeful will 
contain a dose of 0.001 c.mm. of tuberculin. These dilutions may be 
carried further and the dose, which should always be small, if admin- 
istered at all, may be infinitesimally so. 

If given for its psychic effects, which is in fact done at present by 
most who use this agent, it is advisable to have ten bottles and that 
the first injection should be made from bottle No. X. If the patient 
is impressed by the treatment, he will " react" at least with 0.3° to 
0.5° F., which should satisfy any one who is looking for a "mild 
reaction." 

Moreover, there is no difficulty in administering properly a series 
of ascending doses of tuberculin, and no higher mathematics is neces- 
sary for its successful accomplishment. Taking the first injection as 
a unit, we may increase the next injection by one-fourth or one-half. 
Thus, supposing we have used at first the dilution in bottle No. X 
containing 0.0000001 c.mm. of tuberculin per cubic centimeter, we 
inject but one-third or one-half of the contents of the syringe. The 
reaction is not likely to be severe, and we may one or two days later 
increase it to one-half or two-thirds of the contents of the syringe. In 
this manner we may proceed until we reach bottle No. VI, when the 
injection of a syringeful will give a dose of 0.001 cm. It is not advisable 
to give larger doses if we want to make sure that the patient is not 
harmed. But if there is any reaction the injections should be stopped 
promptly. 

Utility of Tuberculin Treatment. — It cannot, however, be denied 
that some good results have been obtained with tuberculin treatment. 
Whether they could not be obtained with other methods in those 
cases is another question. Thus, E. Rist 1 says: "For my part, I have 
never seen a patient doing well under tuberculin without remaining 
in doubt whether he would not have done as well without tuberculin. 
Nor have I met with cases where the influence of tuberculin was so 
strikingly favorable that I could feel justified in letting them abandon 
the classical treatment and rely on tuberculin alone." Sir James K. 
Fowler says: "The tuberculin did not favorably influence the course 

» Paris medical, 19 13, iv, 241. 



PSYCHIC EFFECTS 641 

of the disease in the majority of cases; in some cases the effects were 
detrimental; and even in stationary and improved cases it was difficult 
to ascribe any distinct improvement to the injections which might not 
have been equally attained under the treatment ordinarily employed 
in the Brompton Hospital." 

In the extensive Handbook on Tuberculosis, A. Schroder 1 shows 
that "it has been established that in institutions for the treatment 
of tuberculosis in which only general treatment is applied, the lasting 
results obtained are not inferior to those reported from institutions 
in which, in addition to the general treatment, so-called specifics are 
administered." 

Good results are obtained with tuberculin only when carefully admin- 
istered in sanatoriums, with cases in the incipient stage, with but 
slight lesions, most of which are spontaneously curable. Although, 
according to Brown, at the Adirondack Cottage Sanatorium, no 
selection is exercised — the patients are allowed to elect tuberculin 
treatment. In private practice, as well as in most tuberculosis 
clinics in cities in this country, attempts with tuberculin have failed, 
evidently because the good surroundings, the fresh air, the proper 
food, regulation of rest and exercise were of more importance than 
the tuberculin. When we consider further that even the most ardent 
advocates of tuberculin state that only cases without fever, pursuing 
a slow course, showing no tendency to progress, but manifesting a 
strong tendency to fibrosis, are suitable for the treatment, it is clear 
that tuberculin is a remedy for those forms of phthisis which are 
spontaneously curable. 

Psychic Effects. — We have seen that the tuberculous patient is 
very amenable to suggestion (see p. 257) and we have pointed out 
that in a certain class of cases tuberculin produces excellent results 
for this reason. On this point a large number of physicians agree, and 
they continue to administer tuberculin because of its psychic effects, 
although they may as well administer distilled water hypodermically 
and obtain the same results. To keep nervous, irritable, fretful 
patients for months, or even for years, is a difficult matter; often it is 
an impossible affair. Something must be done in addition to the 
rest, fresh air, milk, and eggs, of which he believes he knows as much 
as his doctor. Such patients, when given tuberculin, told to watch 
out for reactions, to record in detail the symptoms produced by each 
ascending or descending dose on a specially prepared blank, are often 
very much encouraged. 

This view of the psychic action of tuberculin is entertained by most 
authoritative physicians who use this agent extensively. Thus, Law- 
rason Brown, 2 who has done so much to popularize tuberculin in 
this country, says that only poor results can be expected when it is 
given " in cold blood." He believes " its value can be greatly enhanced 

1 Brauer, Schroder, and Blumenfeld's Handbuch der Tuberkulose, 1915, ii, 3. 

2 Am. Jour. Med. Sc, 1912, cxliv, 524. 
41 



642 SPECIFIC TREATMENT 

when the administrator has implicit faith in its curative properties 
and imparts that faith to his patients." Another significant reason 
for using tuberculin treatment according to Brown "is the closer 
relationship that such treatment establishes between patient and 
physician. I must confess that. I find it difficult to bring a patient 
to my office twice a week for months and discuss symptoms and 
fears, one of which gradually grows less while the other is often replaced 
by more or less indifference, born of familiarity. When, how- 
ever, I give this patient tuberculin, he and I can discuss his case in 
detail twice a week and I am able to discover slight but important 
changes in his condition, to check imprudence, and to change needless 
timidity into confidence in his ability to order aright his life." 

But similar results have been obtained by Mathieu and Dobrovici 
with "antiphymose," as was already detailed (see p. 534). In valvular 
heart disease, syphilis, myxedema, etc., this does not work. 

I believe that I am safe in saying that, as a rule, tuberculin treatment 
is only efficacious in intelligent patients who are under the impression 
that they have mastered the theoretical aspects of infection and 
immunity and of specific therapy from reading popular books and 
articles on tuberculosis. In fact, in my experience, uneducated patients 
hardly ever improve under tuberculin treatment because they cannot 
understand the benefit of fever, malaise, pain in the limbs, nausea, 
debility, etc. On the other hand, intelligent patients look forward to 
the reaction as an indication that the tuberculin is "working on their 
system" and they often improve, provided infinitesimally small doses 
have been given. 

There is no agreement among authorities as to what constitutes a 
"reaction" during tuberculin treatment. "All physicians are agreed 
that severe reactions are harmful to the patient, as a general rule," 
say Archer W. R. Cochrane and Cuthbert A. Sprawson, 1 "but there 
is still considerable difference of opinion between those who like their 
course to progress without any reactions at all, and those who prefer 
mild reactions as a routine. Again, opinion varies as to what con- 
stitutes a mild reaction. In dealing with those otherwise running a 
normal temperature, the limit by some has been fixed at 100.4° F., 
and reactions thereto are disregarded; that is to say, these physicians 
will increase the next dose if the last dose has not given a reaction over 
100.4° F." But these authors consider this limit too high or danger- 
ous, and are satisfied with a rise to 99.2° F. and call it a reaction. 
In other words, "the timid, or no-reaction school," treat only 
afebrile cases. They should meet with immense success, because 
this class of patients recover spontaneously, or with any kind of 
treatment. 

Dangers of Tuberculin Treatment. — Since the first use of tuberculin 
as a therapeutic agent, it has been recognized that it is capable of 

1 A Guide to the Use of Tuberculin, London, 1915, p. 60. 



DANGERS OF TUBERCULIN TREATMENT 643 

doing irreparable damage when imprudently administered. Virchow 
found that it produced rapid disintegration of the tuberculous tissues 
in the lungs, caseous pneumonia, and at times eruption of miliary 
tubercles. More recent investigations have shown that it often mobil- 
izes the bacilli and thus may favor metastatic auto-infection. In fact, 
if phthisis was not a manifestation of immunity, disastrous results 
from this cause would be very frequent. It has also been observed 
that patients taking tuberculin for a long time are likely to develop 
nephritis. To be sure, with infinitesimally small doses the likelihood 
of such complications is reduced to a minimum, but the most experi- 
enced administrator is often surprised by unexpected reactions. I 
have seen such results repeatedly; mostly when tuberculin was admin- 
istered by such as were not skilled in handling this potent agent, 
but also at times in patients who were treated by very skilful physi- 
cians. 

Producing hyperemia of the affected lung area, tuberculin at times 
is effective in inducing pulmonary hemorrhage. When large doses 
were used this was very frequently observed and reported by Frankel, 
Rumpf, Strieker, and many others. "Since small doses have been 
used," says J. Sorgo, 1 "with a view of avoiding strong reactions, 
hemoptysis is only rarely observed after the administration of tuber- 
culin. At times small hemoptyses are seen, especially streaky sputum, 
but copious hemorrhages are rare. For this reason it is agreed that a 
tendency to hemoptysis is not altogether a contra-indication to tuber- 
culin treatment, provided strong reactions are avoided." But, as 
we already mentioned, this is not possible in every case. All who 
administer tuberculin for therapeutic purposes stop the treatment 
as soon as bleeding makes its appearance. 

The general practitioner should not use tuberculin at all. He can 
obtain the same results by the judicious use of drugs without incurring 
any risk. Even psychotherapy of the kind applied by those who 
administer tuberculin can easily be practised with medication, as 
was shown in Chapter XXXIX. 

1 Brauer, Schroder, and Blumenfeld's Handbuch der Tuberkulose, 1914, ii, 255. 



CHAPTER XLI. 
SYMPTOMATIC TREATMENT. 

Cough. — To many patients the cough is the disease and they are 
under the impression that all they need for a speedy recovery is to be 
rid of this annoying and painful symptom. In its treatment some 
points are to be borne in mind: In most cases cough is decidedly con- 
servative — a purposeful reflex act; it removes the secretions from the 
respiratory passages which, if retained, might act like foreign bodies 
or produce toxic effects. But, on the other hand, cough often dis- 
turbs the affected tissues which need rest, if cicatrization is to occur, 
or it may be responsible for insomnia, hemoptysis, pneumothorax, etc. 
Usually these conflicting principles can be reconciled by appropriate 
treatment. 

Cough can be prevented or ameliorated by simple measures in a 
large proportion of cases. Atmospheric purity contributes consider- 
ably toward a reduction in its frequency and severity. Outdoor 
life and good ventilation of the room inhabited by the patient meet 
this indication. Mouth-breathing is a cause of excessive coughing in 
many cases, and some get fits of coughing when suddenly changing 
from a warm into a cold atmosphere, or the reverse. In steam-heated 
rooms, in which the air is usually dry, cough is more frequent than in 
rooms in which the air contains a proper amount of moisture. 

In advanced cases with secreting cavities, the cough may be influ- 
enced by posture; reclining on one side, expectoration is facilitated, 
while lying on the other side brings about violent fits of coughing. 
Patients soon find out which position gives them relief and recline 
accordingly. These patients may only cough during the morning 
hours and thus empty their cavities of the secretions which have 
accumulated during the night, while during the day there is but little 
cough. They need no treatment for this symptom. 

It will be observed that some phthisical patients who sleep well 
during the night, cough more during the day than those who cough 
more or less during the night. The administration of large doses of 
opiates during the evening may gain relief in sleep, but also result in 
miserable hours during the following day. This is to be remembered 
when administering opiates to tuberculous patients. 

Psychotherapy of Cough. — It is a noteworthy fact that the cough is 
greatly influenced by the psychic state of the patient. Persons with 
an irritable nervous system, the hysterical, emotional and neurasthenic, 
cough more than the dull, the phlegmatic and apathetic. Some cough 
while in the house and are relieved as soon as they go out into the 



COUGH 645 

open air, while in others the cough increases as soon as the window is 
opened, or when they go out into the open air on a cold day. This 
last class of patients is very difficult to manage. 

Other psychic influences are seen in patients who usually cough 
excessively but cease when in agreeable company, or are intensely 
interested in something, etc. I have practically stopped unproductive 
cough in many patients by threatening them with expulsion from 
the hospital if they did not cease annoying their fellow-sufferers in 
the ward. Lonesomeness and also insomnia are often responsible 
for excessive cough and should be treated according to indications. 
In sanatoriums the influence of example is often very good: The 
patient sees others control their cough and attempts to do likewise 
and is often surprised at his success. 

The patients can, within certain limits, control their cough, as 
Galen pointed out more than seventeen centuries ago, and Dett- 
weiler has shown that this symptom can be "disciplined." Even 
when the cough is productive of considerable quantities of sputum, 
the patient is to be instructed that he need not expel it all at once; 
that if he succeeds in suppressing it for some time, the accumulated 
sputum will later be brought out with little effort. During the morning 
hours patients often make strong efforts to clear their chests. But if 
they should wait till after breakfast they may find that the sputum 
comes up easily. "Cough induces cough," says Penzoldt, 1 and for 
this reason patients are to be warned against giving in to the first 
tickling of the throat. The great struggle will only be during the 
first two or three days. Meeting with success, patients become con- 
vinced of their own powers to suppress or control this symptom. 

But patients must be warned in this connection against swallowing 
their sputum — "spitting into their own stomachs." Controlling does 
not mean entirely suppressing expectoration as women and some 
men are apt to do. The dangers of the habit are to be explained in 
detail to the patient. 

I cannot agree with those who prohibit smoking to tuberculous 
patients indiscriminately. To be sure, those who are not accustomed 
to tobacco often cough when near a person who smokes. But many 
habitual smokers are greatly relieved by a cigar or a cigarette. ^ Our 
advice should be in accordance with the experience of the individual 
patient. 

Many home remedies are very often efficacious in relieving cough. 
Thus, equal parts of boiled milk and honey or glycerin, with or with- 
out a flavoring agent, may be of great use in stopping an annoying 
cough. An excellent remedy is the application of a small mustard 
leaf or blister over the seat of the lesion. It may be repeated from 
time to time. The fact that it works by psychic suggestion should not 
deter us from using it, so long as the patient gets relief. 

i Handbuch der Therapie, 1910, iii, 249. 



646 SYMPTOMATIC TREATMENT 

Medicinal Treatment. — After all the cases in which the cough may 
be controlled, or made bearable by simple methods, are discounted, 
there remain a large number who must be given sedatives to control 
this symptom. In the incipient stage these remedies are only rarely 
called for, and then only for a short time. But in advanced cases the 
indications for sedatives become more and more urgent. As Penzoldt 
says, the more progressive the disease and the less the chances of 
ultimate recovery, the more the charity of morphin is to be dispensed 
to the unfortunate sufferer. 

In my experience, many cases in the incipient and moderately 
advanced stages of the disease are immensely relieved by creosote and 
its derivatives. The method of administration is given elsewhere. 
In those in whom internal administration does not relieve the cough, 
we may try the effects of inhalation of creosote, menthol, eucalyptol, 
tincture of benzoin, etc. The following is as good as any that has 
been recommended: 

1$ — Creosoti, 

Acidi carbolici. 

Spir. chloroformi aa 5iv 15 . 

M. S. — Ten to twenty drops in an inhaler, to be used for fifteen minutes at a time. 

Failing with these simple remedies we must resort to anodynes in 
case the cough is frequent, violent, paroxysmal, or disturbs the patient's 
comfort or sleep. Of these, cannabis indicse is the least harmful and 
should be given the first trial. The extract may be given in doses of 
} grain in pill or tablet form several times a day. In spasmodic 
cough it may be combined with hyoscyamus or gelsemium. The fol- 
lowing may be used to great advantage: 

1$ — Extracti cannabis indicse gr. vj 0.4 

Extracti hyoscyami gr. xij 0.8 

M. ft. pil. No. xxiv. 

S. — One pill four to six times a day. 

~fy — Extracti cannabis indicse fl., 

Extracti gelsemii fl aa 5ij 8.0 

Syr. acacia? ■ . • • 5J 30.0 

Aquae menthae piper ad 5iv 120.0 

M. S. — One teaspoonful four times a day. 

In many cases nothing but opiates gives relief. But in incipient cases 
opium and its derivatives are to be avoided because it may have to 
be continued for long periods and, in hopeful cases, the danger of habit 
formation is not negligible. In addition, opium deranges the digestive 
functions, produces anorexia and constipation, slows the frequency 
and the amplitude of the respiratory movements, and favors stag- 
nation of the secretions in the respiratory passages. A dose of Dover's 
powder may be given in the evening now and then with a view of 
controlling the cough during the night, but to continue the adminis- 
tration of opium in any form for any length of time is dangerous. 



COUGH (547 

Of the many opiates, codein, which is ten to twelve times less toxic 
than morphin, is to be preferred. It may be given in tablet form in 
doses of i to i grain, and in advanced cases even in much larger 
doses several times a day; or it may be added to any other medica- 
tion that is being administered. Thus I quite often add it to creosote 
medication : 

1$ — Guaiacolis carbonatis 3iiss 10 

Strychninae sulphatis gr. j o 06 

Arsenici trioxicli gr . j . 06 

Codeinse phosphatis gr. viij 0.5 

M. ft. capsul. No. 1. 

S. — One capsule three times a day after meals. 

1$ — Codeinse sulphatis '...'. gr. iv 0.3 

Extracti cannabis ind^cse gr. vj 0.4 

Extracti belladonnae gr. iij 0.2 

Extracti glycyrrhizse gr. xij 0.8 

M. ft. pilullae No. xii. 

S. — One pill at night. 

In most cases in which sedatives must be given for a considerable 
time the dose must soon be increased because after a few weeks the 
effects on the cough are diminished. Instead of increasing the dose, 
we may do better by changing one for some other derivative of opium. 
Heroin may be given in doses of ^V to f grain according to indications. 
It does not constipate and when there is dyspnea it is the best palliative 
remedy. Dionin is another of these preparations and, when insomnia is 
a troublesome feature, it is even better than the above. Not many 
cases of habituation to dionin have been reported, but it is more apt to 
cause constipation than codein or heroin. The two last-mentioned 
preparations do not interfere with the expectoration of sputum; some 
even maintain that they assist in its expulsion. Whenever feasible, 
these narcotics are not to be given after midnight in order to avoid 
headache and debility during the morning hours. 

The emetic cough is a very difficult symptom to control in some 
cases. I have seen some in whom it was responsible for a bad turn in 
an otherwise favorable case. Rarely, no food can be retained. Most 
can be relieved by avoiding heavy meals — taking several small meals 
during the day. The patient should recline in bed immediately after 
meals and avoid any exertion and even speaking. But at times we 
must resort to medication. Some have reported good results from 
several drops of chloroform well diluted, or from bromoform. I have 
had cases in which only cocain administered before meals was effective 
in retaining nourishment in the stomach. The following prescription 
of Albert Robin may have to be resorted to: 

3— Cocain hydro chloratis gr. j • 06 

Codein sulphatis ■'&;.* ° 06 

Aquae chloroformi 5ij 60.0 

Aquae ad §iv 120.0 

M. S. — Tablespoonful after meals. 



648 SYMPTOMATIC TREATMENT 

Expectoration. — In the average case of phthisis expectoration is a 
salutary phenomenon, removing, as it does, foreign, often toxic, 
material from the respiratory passages. At times it becomes excessive 
and annoying, but it should never be suppressed. In some cases with 
extensive excavations the amount of sputum brought up may be 
controlled within limits by posture. We advise our patients to recline 
in certain positions which favor the expulsion of sputum and thus 
empty the cavities of their contents. Relief may thus be obtained 
for the rest of the day. In cases in which the sputum is fetid — rare 
in phthisis — antiseptic inhalations may be tried. Creosote, iodin, 
menthol, eucalyptol, turpentine, etc., may be inhaled through an 
inhaler or simply dropped in hot water and inhaled. 

Very often patients complain that they feel heavy on the chest and 
that if they could only bring up sputum they are confident that they 
would be relieved. Many drugs have been used for this purpose, 
especially the so-called expectorant remedies. It seems that all that 
is usually attained is a disordered stomach. 

It appears from recent pharmacological investigation that there are 
no drugs which, when given in small doses, will induce more abun- 
dant secretion into the respiratory passages, stimulate the cilia of the 
bronchial mucous membrane to bring out secretions, or render tena- 
cious secretions more easily movable from the bronchial walls to 
which they adhere. J. L. Miller 1 found that ammonium carbonate 
and ammonium chloride, and the emetic group of expectorants, as 
apomorphin and ipecac, when given in sufficiently large doses to 
animals, increase the bronchial secretion. Ammonia salts per os, in 
moderate doses equivalent to 2 mg. in an adult man, do not increase 
bronchial secretions in the dog. Apomorphin and emetin, when given 
to dogs in doses considerably greater than the ordinary therapeutic 
dose for man, do not excite increased bronchial secretion. 

It is therefore absurd to give nauseating potions of ammonium 
salts, senega, ipecac, apomorphin, etc. All we may succeed in doing is 
to disorder the stomach, but the secretion in the respiratory passages 
remains unaffected. 

Fever. — Fever is an indication of active, often progressive phthisis, 
unless due to some complication. Its continued presence proves con- 
clusively that the disease is spreading, even if the physical signs remain 
unaltered. It is at times neglected or overlooked because, unlike fever 
in other diseases, the patient in spite of a temperature of over 100° F. 
may feel quite comfortable, have a good appetite, and even gain in 
weight. But the entire future of the patient may depend on the 
treatment of the fever; neglecting mild febrile attacks means an invi- 
tation for chronic prolonged fever with lessened chances of recovery. 

During the initial stages of the disease fever demands rest in bed, 
not so much as a cure but as a preventive against the extension of 

1 Am. Jour. Med. Sc, 1914, cxviii, 469. 



FEVER 649 

the process in the lung. It is remarkable that in many cases the fever 
abates within a few days or a week only through an improvement in 
the hygienic conditions and the diet of the patient, and placing him 
in a light and well- ventilated room. It is unfortunate that very few 
patients are willing to submit to perfect rest at this stage, claiming 
that they are not sick. 

There are many advanced cases of phthisis with quite extensive 
lesions in which there is a daily rise in the temperature of 1 to 1.5° F., 
but the patients feel quite well and are even able to pursue their 
vocations. They need no active treatment because they have become 
habituated to the subfebrile temperature which may be regarded as 
their normal condition. In this class of cases it is only necessary to 
take steps to reduce the temperature when the patient is clearly 
suffering as a result of it; when the fever produces symptoms such 
as anorexia, restlessness, irritability, insomnia, etc.; or w T hen he is 
losing in weight. I have observed many cases in which fever was due 
to overfeeding, and a reduction in the quantity of food has promptly 
brought the temperature down to normal. 

A sudden rise in the temperature in the course of chronic phthisis 
may be due either to an extension of the lesion, a new pneumonic pro- 
cess in a hitherto unaffected part of the lung, or to some complication. 
The former demands rest in bed till the temperature comes down to 
normal; in the latter the indications are in accordance with the 
pathological conditions which present themselves. 

Patients are apt to attribute an attack of fever to "indigestion," 
but in my experience acute gastritis is a rather infrequent cause of 
pyrexia in phthisis, though a dose of calomel at times relieves an 
evanescent febrile attack. More often fever lasting several days is 
due to influenza or tonsillitis. In hospital practice there is seen at 
times an actual epidemic of these diseases; most of the patients in the 
ward are attacked during a period of a couple of weeks. The treat- 
ment is rest in bed and some antipyretic, like antipyrin, quinin, aspirin, 
etc. Complicating pleurisy, with or without effusion, may be the 
cause of a rise in temperature. In some women premenstrual or 
menstrual fever demands rest in bed periodically for a few days. The 
instability of the temperature in phthisis, which has been discussed in 
a previous chapter, is responsible for many febrile attacks^ Any 
physical or mental exertion, worry, grief and anxiety may raise the 
temperature several degrees. Prophylactic and curative action is 
indicated along these lines. 

The fever accompanying active phthisis demands active treatment. 
The main aim should be to remove it or to prevent its occurrence. If 
we fail in this, we fail in our efforts at relieving the patient. It may 
very often be prevented by putting a patient to bed at the very first 
indication of a tendency to hyperthermia from any cause. Indeed, 
the neglect of mild febrile attacks is very often responsible for pro- 
longed and even fatal fever. 



650 SYMPTOMATIC TREATMENT 

In high continuous fever perfect rest is indicated, preferably in the 
open air, or in a room with wide open windows, as has already been 
detailed in Chapter XXXIV. The patient is to be treated as though he 
is suffering from an acute disease, like typhoid or pneumonia. It is 
often surprising to note the prompt improvement after a rest in bed 
for a few days. Patients with a temperature at a high level for several 
months are often difficult to manage. When accompanied, as it 
usually is, by progressive loss of appetite, weight, and strength, they 
become discouraged and rebel against the prolonged and strict con- 
finement. In such cases, provided the temperature is below 101° F., 
the experiment may be made of permitting them to leave the bed and 
get out in the open, resting on a reclining chair for a few hours dining 
the day. The best hours are before or around midday, when the tem- 
perature is usually at its lowest; but any other time may be chosen 
under the guidance of the thermometer. In hectic cases the tempera- 
ture is usually at its lowest in the morning and the patient may be 
allowed to leave his bed at that time. I have seen many patients, who 
did badly for weeks, improve when allowed to remain in the upright or 
semiupright position for several hours a day. But care and circum- 
spection are to be exercised while applying this treatment. 

Some patients may be sent to the country and the change is at times 
effective in reducing the temperature when everything else has failed. 
But this is not available to patients who have not the means to leave, 
accompanied by an attendant. Many authorities state that a moun- 
tainous climate is to be preferred for this purpose, but in my expe- 
rience any change may do just as well. 

It is deplorable that public sanatoriums do not admit febrile cases. 
Great service could be rendered by removing the patient for several 
weeks, during the period of fever, to better surroundings, giving him 
an opportunity to rest without interference by well-meaning, but often 
ill-guided, relatives and friends. I have often felt that cases under 
my care could be saved if sanatoriums were managed along hospital 
lines, admitting patients during acute exacerbations in the places 
which are now filled with patients whose condition is such that they 
would do well in any healthy surroundings which can be obtained in 
the average home. 

Hydrotherapeutic measures have not been found satisfactory in the 
treatment of fever in phthisis. The use of ice, or of cold sponging, or 
bathing, although possibly of temporary benefit, is contra-indicated 
in most cases because they are apt to depress the patient. The most 
that can be done is to give a warm or tepid bath once or twice a week 
for the purpose of cleansing the body, but care is to be taken not to 
subject him to overexertion while going and coming from the tub. 
The fact that hydrotherapeutic methods have been given up in nearly 
all sanatoriums is sufficient proof that they have not been beneficial; 
in fact, that they are harmful. 

Artificial pneumothorax is an excellent radical measure against 



FEVER 651 

tuberculous fever in appropriate cases. This will be discussed in 
Chapter XLII. 

Antipyretic Medication,— Antipyretic drugs should only exceptionally 
be used in phthisis. In the first place, tuberculous patients do not, as 
a rule, suffer from the pyrexia to the same' extent as patients with 
typhoid fever, pneumonia, etc., and a reduction in the temperature 
does not necessarily give the relief which the patient anticipates. It 
is not the fever, excepting hyperpyrexia, which is dangerous, but the 
activity of the tuberculous process, and so long as only the former is 
influenced, the patient is not materially benefited. 

The action of antipyretic drugs is ephemeral and deceptive, often 
accompanied by profuse perspiration which is enervating; and by 
digestive disturbances. Large and frequently repeated doses are 
necessary for weeks in the usual cases and their action on the heart, 
which is not salutary, often leads to collapse. 

But when the fever is accompanied by headache, backache, and 
debility, one of the coal-tar antipyretics may give comfort with or 
without reducing the temperature. Acetanilid is to be avoided for 
well-known reasons. Phenacetin acts too quickly and produces profuse 
sweating. Antipyrin, or better, pyramidon may be used in 5- to 10- 
grain doses, combined with caffeine. Patients may stand the fever 
without complaining much, but in septic cases they abhor the chills 
which are apt to occur before the onset of the pyrexia. The best 
treatment is to place the patient in bed a few hours before the appear- 
ance of the chill, cover him well, and give him a drink of hot lemonade, 
tea, or whisky and, in severe cases, a dose of pyramidon. The chill 
may not be prevented completely in this manner, but it is rendered 
bearable. On the whole, antipyretic medication is to be administered 
an hour or so before the highest temperature is expected, varying 
with each case. Quinin should be given, if at all, five to six hours before 
the maximum temperature is expected, while pyramidon, antipyrin, 
aspirin, etc., require but two to three hours. When the fever has 
declined medication should not be continued, otherwise collapse may 
occur. 

The salicylates are often very good in these cases, especially in the 
chronic hectic fever of consumption. The old prescription of sodium 
salicylate and arsenous acid (sod. salicyl., 10; acid, arsenicosi, 0.01 ; 
ft. pil. no. 100; S., five to ten pills three times a day after meals) is 
very good. But I have found that 7 to 10 grains of aspirin and T fo 
gr. of arsenic in capsule three times a day are better. It is less likely 
to disturb digestion. But in patients showing a tendency to hemop- 
tysis the salicylates are to be avoided. Pyramidon is best for this 
class of patients. 

An excellent remedy for fever in tuberculosis is guaiacol painted with 
a camel-hair brush on the skin in 7- to 15-drop doses and covered 
air-tight. The temperature drops sometimes within one hour. It is 
best to rub into the skin of the thorax a teaspoonful of a 10 per cent. 



652 SYMPTOMATIC TREATMENT 

guaiacol-vaselin ointment two or three times a day. It must be 
mentioned that collapse has been observed in some cases after the 
application of guaiacol. 

Nightsweats. — Xo other symptom of chronic phthisis is more dis- 
couraging and enervating than nightsweats and their relief is of 
immense importance. It seems that in the vast majority of cases they 
can be prevented without the use of medication and many physicians 
state that with careful prophylaxis they have not used any drugs for 
this symptom for years. 

Open-air treatment is the best preventive of nightsweats. Sleep- 
ing in a cold room with sufficient but not excessive covering must 
be enjoined. It is also good to give the patient before retiring a glass 
of cold milk with three or four teaspoonfuls of cognac to prevent the 
rapid sinking of the pulse-rate. In some cases a roll with butter may 
serve the same purpose. Some cases may be relieved by noting the 
time of the beginning of the sweating, and waking the patient a few 
minutes before and giving him an ounce of whisky. For private patients 
an alarm clock may be used for the purpose. This method, recom- 
mended by William Porter, 1 should be tried in all obstinate cases. 

In cases in which these simple measures do not succeed, the sulphate 
of atropin in doses of y^- grain, given in tablet form about seven 
o'clock in the evening, may give complete relief. Agaricin is also good 
in doses of ^o grain, but it acts more slowly and must be adminis- 
tered about six hours before the sweating is expected. It often produces 
gastro-intestinal disturbances, especially diarrhea, and should be com- 
bined with an opiate — Dover's powder in 3- to 5-grain doses. Cam- 
phoric acid, in 10 to 20 grain doses, may be tried in obstinate cases. 
It is to be remembered that no remedy retains its power over this 
symptom for a long time, and after one ceases to act, we may try 
another. 

Friction of the skin with tepid water, or vinegar or alcohol and 
water, or a 3 per cent, lysol solution, may give relief. 

Hemoptysis. — The prophylaxis of hemoptysis cannot be considered 
a simple matter despite the fact that we speak so much about the pre- 
disposing and exciting factors of pulmonary hemorrhage. Patients 
with really initial hemorrhages nearly always consult us only after the 
accident has occurred. Overexertion, excitement, etc., as exciting 
causes of pulmonary hemorrhages, have recently been shown to have no 
etiological relation in the vast majority of cases. It appears that most 
hemorrhages, especially those which are copious and fatal, occur during 
the night, or when the patient has been at rest. S. Bang 2 has recently 
made a special study of this problem and found that among 2000 tuber- 
culous patients in a sanatorium, the initial hemorrhages came on while 
the patients were lying in bed, or in a reclining chair, in 69 per cent, of 
354 cases; in 15 per cent, while they were dressing, sitting up in bed 

1 International Clinics, Sixteenth Series, 1906, iv, 77. 

2 Ugeskrift for Laeger, 1916, lxxviii, 419. 



HEMOPTYSIS 653 

or just lying down; and in only in 6 per cent, of cases while the patients 
were walking or working; and in 8 per cent, while they were other- 
wise engaged. In only two of the total number were the patients 
climbing stairs though he estimates, that these 2000 patients must 
have climbed the stairs over a million times, and taken 10,000 warm 
baths, and 25,000 douches while at the sanatorium. These facts, which 
may be duplicated by observations of any physician with large experi- 
ence, show conclusively that overexertion is but a negligible factor, if 
any at all, in hemoptysis. 

It appears that in active and progressive cases pulmonary hemor- 
rhage is often the accompaniment of acute exacerbations of the disease. 
In rare cases we meet with hemoptysis, or even with fatal hemorrhages, 
in an entirely afebrile patient. But in most instances, fever, tachy- 
cardia, etc., precede the onset of the bleeding by several days. Bang's 
statistics substantiate this observation. Many patients suffering 
from acute exacerbations, or from febrile complications, have attacks 
of hemoptysis; at times, profuse hemorrhages. The prophylaxis in 
these cases is thus clearly the prevention of the acute exacerbations, 
or the febrile complications, which are liable to produce stasis and con- 
gestion of the involved lung area. The smaller hemorrhages are usually 
the result of diapedesis, being of parenchymatous origin, and have 
nothing to do with the position of the body, nor with overexertion or 
excitement. 

The copious pulmonary hemorrhages, due to erosion of a pulmonary 
bloodvessel, can hardly be foreseen nor prevented; they are due to 
the involvement of a bloodvessel in the tuberculous process, with 
softening of its wall, thus allowing the blood to escape before a thrombus 
has formed. In others, it is due to the rupture of an aneurysm of 
Rasmussen, as was already shown in the chapter on Pathology. To 
speak in these cases of prophylaxis is futile. 

All patients with pulmonary tuberculosis are to be told in advance 
that there is less danger in blood-spitting than is generally believed. 
We would thus avoid the psychic depression which is so often an 
accompaniment of hemoptysis. Women may be told that in the aver- 
age case of hemoptysis there is no more danger than in the loss of blood 
during the menstrual period. 

Not all cases of hemoptysis require the same treatment; individ- 
ualization is required here, just as in most other pathological condi- 
tions. The vast majority of hemorrhages are insignificant, and if we 
only quiet the patient by an assurance that there is little danger, the 
bleeding will cease sooner or later, and the underlying process in the 
lung pursues its course uninfluenced by the accident. This is true of 
streaky sputum, which often terrorizes a patient to the same extent as 
a copious hemorrhage. But when the blood brought up is bright red, 
even if only a few mouthfuls, the matter is to be taken more seriously, 
because these small hemorrhages are at times the precursors of repeated 
and copious, though rarely uncontrollable, hemorrhages. 



654 SYMPTOMATIC TREATMENT 

The patient is put to bed, but not in the traditional prone position. 
The blood and sputum must be evacuated from the respiratory pas- 
sages with ease and this can only be done when the patient is in the 
semi-sitting position. In this manner nourishment and medication 
can be administered without unduly disturbing the patient, espectora- 
tion is facilitated and in copious hemorrhages, atelectasis of the pos- 
terior parts of the lung is prevented; eating, the administration of 
medicines, vomiting, and the toilet are thus facilitated. The time- 
honored ice-bag applied to the chest is of no value at all, excepting to 
keep the patient busy and attentive while attempting to keep it in place. 

I have thus treated during the past three years nearly all the cases of 
hemoptysis under my care and found that the bleeding ceased just as 
quickly as when I applied the rigid-rest treatment. The psychic effect 
has even been more salutary. The patients are not so frightened as 
when they are warned that the least motion of the body, any word 
uttered, may increase the bleeding. It is best to place the patient in 
the semi-upright position immediately after the bleeding begins 
because, as has been pointed out by Bang, rising in bed from the recum- 
bent to the sitting position involves contraction of the abdominal 
muscles. These are liable to press upon the vena cava as in straining 
at stools, and by reflex action from the splanchnic nerve, cause an 
increase in the bleeding. This is probably responsible for the experi- 
ence that sitting up in bed causes an increase in the flow of blood. It 
may be averted by placing the patient from the start in the half-seated 
position. 

The therapeutic indications to be met are : Prevention of excessive 
cough and expectoration; increasing the coagulability of the blood 
and immobilization of the bleeding lung. 

Morphin.— To allay excitement, procure rest, and thus prevent exces- 
sive cough, there is no better remedy than a hypodermic injection of 
morphin. We must bear in mind that we are in the presence of a 
conflicting situation. On the one hand, we must see to it that the 
effused blood in the bronchial tree should be removed; on the other 
hand, the strong expiratory efforts necessary to accomplish the expul- 
sion of the blood and clots are accompanied by an increase in the 
pressure in the pulmonary circulation and, with their removal, the 
thrombi which plug the bleeding vessel are dislodged and thus renewed 
bleeding is likely to occur. Morphin meets but one of these indica- 
tions: It depresses the cough center, diminishes the frequency and 
amplitude of the respiratory movements, and quiets the mental state 
of the patient. Some have even found that morphin increases the 
coagulability of the blood. But after all it has its dangers. When 
given to excess, as is often done, it depresses the respiratory center, 
paralyzes the sensibility of the bronchial mucous membrane and thus 
interferes with the expulsion of the blood and clots. Aspiration 
pneumonia may thus result in cases in which it is more successful as 
a hemostatic than is desirable. 



HEMOPTYSIS 655 

For this reason morphin is to be used with great care and circum- 
spection. Finding the patient excited and in agony, we inject hypo- 
dermically \ grain of morphin for its general and local effects. If the 
bleeding does not stop within an hour, the morphin should not be 
repeated, but other means are to be taken to control the hemorrhage. 

Emetin. — In former time emetics were given in hemoptysis and excel- 
lent results were reported because, with the vomiting, the effused blood 
in the bronchi was also expelled, preventing asphyxiation and also 
because the nauseous feeling reduced the blood-pressure perceptibly. 
Following Trousseau's suggestion, large doses of ipecac were given for 
this purpose. But we now have in emetin an excellent substitute for 
the nauseous ipecac. It acts as a hemostatic when many other agents 
have failed. I have used it in f-grain doses, repeated three to five 
times a day, with satisfaction. The simplest way of administration in 
these cases is hypodermically. Either the tablets or the ampoules, 
which many pharmaceutical houses prepare, may be used for the 
purpose. 

Salt. — Another ancient remedy for copious hemorrhage is the ad- 
ministration of table salt. Formerly it was thought that because 
it acts as an emetic, and thus depresses the blood-pressure, it is of use 
in hemoptysis. But we now know that its modus operandi is different. 
Von den Velden 1 has proved that, in man, swallowing 5 to 15 grams of 
table salt increases the coagulability of the blood within five minutes. 
Within one hour the coagulatility returns to its former intensity. 
Sodium bromide has nearly the same effect. For this reason the 
administration of 5 to 10 grams of table salt or 3 grams of sodium 
bromide three to four times a day may prove of immense value in 
hemoptysis. In very nervous patients the bromide is to be preferred. 

More recently salt has been administered intravenously in isotonic 
solution, as recommended by Hans Miiller. 2 Ten to 50 c.c. of a 10 per 
cent, solution of sodium chlorid, sterilized and heated to the body 
temperature, are injected into the median basilic vein, great care being 
taken not to drop any of the solution into the subcutaneous tissue, 
which is likely to cause intense pain. I have tried this treatment but 
have not found it superior to other methods. 

Tying the Extremities.— The coagulability of the blood is also in- 
creased by tying up the blood in the extremities. A constricting band, 
or a tourniquet, is tied around the arm and the hip; two or three of the 
extremities are tied up at a time. In order to avoid injury to the 
nerves a roller bandage, or any other soft pad, should be placed under 
the tourniquet over the path of the larger vessels. The bandage should 
not remain in place for more than two hours, otherwise muscular 
paralysis or necrosis of the skin may result. As a rule, one-half hour 
is sufficient. The bandage is to be loosened slowly, by degrees, for 
obvious reasons. 

: Ztschr. f. exper. Pathol, u. Therapie, 1910, vii, 290. 
2 Beitr. z. Klinik d. Tuberkulose, 1913, xxviii, 1. 



656 SYMPTOMATIC TREATMENT 

Artificial Pneumothorax. — In cases in which the above measures are 
of no avail, the induction of an artificial pneumothorax may be con- 
sidered, provided it can be ascertained in which side of the chest the 
bleeding is going on. This point is discussed elsewhere in this book. 
But it should be stated that in .very acute cases, in which the exsan- 
guination is sharp and brisk, there is usually nothing to lose and, even 
when we are not sure, we are justified in inducing a pneumothorax in 
the pleura of the lung which is most likely the source of the bleeding, 
as shown by clinical indications. When the bleeding lung is collapsed, 
the bleeding stops immediately. 

Medicinal Treatment. — It will be noted that with the exception of 
emetin we have left to the end the drugs which have been used for the 
purpose of allaying pulmonary hemorrhage. The reason is that we do 
not know of any drug which will stop hemorrhage in the lung. It seems to 
me that the reputation of some drugs as pulmonary hemostatics has 
been acquired on the basis of the fact that the vast majority of hemor- 
rhages stop spontaneously; anything will do and receive the credit. 
This appears to be the consensus of opinion of phthisiotherapeutists 
at present, although no less an authority than Albert Robin 1 says 
that he feels constrained to protest vigorously against the allegation 
that medicinal agents are impotent, and are only given credit for their 
psychic effects. To be sure, he says, there are many cases of hemop- 
tysis which stop spontaneously, with or without treatment; there 
are others which cannot be controlled by any treatment. But between 
these two extreme types there are many cases in which medicinal 
treatment has a decidedly beneficial influence. Among these drugs 
Robin mentions ergot, calcium chlorid, gelatin, trinitrin, adrenalin, 
ipecac, digitalis, etc. 

The Nitrites. — The nitrites have been found efficient in checking 
the bleeding from the lung. They are known to lower the blood- 
pressure and this may be the cause of their efficacy. Macht 2 found 
experimentally that the nitrites cause a constriction of the pulmonary 
vessels and at the same time they are efficient peripheral and splanchnic 
vasodilators. As usually given in 2 or 3 drops, amyl nitrite is often 
inefficient. I found that J. E. Squire's 3 suggestion to give 10 to 15 
drops, dropped on a handkerchief which is placed before the patient's 
mouth and nose, is best. Immediately the face becomes red and con- 
gested and the hemorrhage stops. It may be repeated several times 
during the day. In more copious hemorrahges, where the nose gets 
blocked up with blood and clots, it may be necessary to put from 30 
to 50 minims on a piece of lint and hold it over the patient's mouth. 
It may have to be repeated and the only complaint heard from the 
patient is that it produces a feeling of nausea. C. Fochi 4 says that 

1 Therapeutique uselle de la tuberculose, Paris, 1912, p. 294. 

2 Jour. Am. Med. Assn., 1914, lxii, 524. 

3 Clinical Journal, 1909, xxxiv, 155. 

4 Gazetta degli Ospedali, 1908, xxix, 114. 



HEMOPTYSIS 657 

when administered as soon as the first traces of blood-spitting are 
seen, copious hemorrhages may be prevented. But this is open to 
question. Fatal hemoptysis only rarely begins with streaky sputum. 
It is copious from the start, as a rule. 

In slow bleeding, nitroglycerin, given in small and frequently 
repeated doses, as recommended by Flick, is often of service. When 
administered in 2- to 4-drop doses of the 1 per cent, alcoholic solution 
it produces the same effect as amyl nitrite, but slower and more lasting 
effects are observed. Tablets are not to be trusted because they are 
often inert, as has been shown by George B. Wallace and A. I. Ringer. 1 
The 1 per cent, solution, as represented by the pharmacopeial spirits, is 
the best form in which glonoin should be administered. The following 
formula may be prescribed : 

1$ — Spirit, glonoini 3j 4.0 

Aquae aurantii flor §j 30.0 

Aquae destil ad 3iv 120.09 

M. S. — One teaspoonful three or four times a day. 

Adrenalin. — During recent years adrenalin has been used quite 
extensively for hemoptysis. It has been stated that it works well in 
cases where it is likely that the hemorrhage is due to the erosion of 
a medium-sized vessel, and that in acute inflammatory conditions 
of the lung it is contra-indicated. It increases the heart action and 
contracts the bloodvessels, especially of the intestines, kidneys, and 
spleen, and thus increases the blood-pressure. But Gerhardt says that 
the bloodvessels of the lung are but slightly contracted, while Frey 
found that in a bleeding lung in a rabbit the vessels dilated and the 
flow of blood was increased after the administration of adrenalin, and 
Macht 2 found experimentally that it causes a powerful constriction of 
the pulmonary artery. Moreover, according to von den Velden, the 
coagulability of the blood is increased 50 per cent, after the sub- 
cutaneous administration of the remedy. Clinical experience with 
this drug has not convinced the writer of its efficacy in hemoptysis 
and it has therefore been discarded. 

Ergot. — Ergot has been given in large doses (a teaspoonful of the 
tincture every three or four hours; ergotin hypodermically) . But it 
has been conclusively shown that it increases the pressure in the 
lesser circulation, just what we want to avoid. In the writer's experi- 
ence it has never been of any value; often decidedly harmful. The 
same may be said about digitalis. 

Atropin.— Atropin administered hypodermically, in doses of ¥ V grain 
every three or four hours, according to indications, has been of more 
service than ergot or digitalis. Still, in some cases the writer has 
observed an increase in the hemorrhage soon after its administration. 

Gelatin.— With a view of increasing the coagulative power of the 
blood, gelatin has been recommended by Dastre and Floresco, 3 though 

1 Jour. Am. Med. Assn., 1909, Hi, 1629. 

2 Jour. Pharmacol, and Exper. Therap., 1918, hi, 243. 

3 Compt. rend de la Soc. de biol., 1896, hi, 243. 
42 



658 SYMPTOMATIC TREATMENT 

there is evidence that the Chinese have used it as a hemostatic as far 
back as the third century. Four to 6 ounces of a sterilized 3 per cent, 
solution of gelatin are injected under the skin of the abdomen or thigh. 
Great care must be taken in preparing the solution, as well as while 
injecting it, because severe cases of sepsis, even tetanus, have been 
reported. Altogether it is not a harmless procedure — it is painful, 
leaves painful infiltrations at the site of the injection, often provokes 
fever, and is followed by urticarial eruption. If gelatin is used at all it 
should be given by mouth. The patient may be given jelly made from 
calves' legs, etc., or gelatin may be mixed with milk; or a concentrated 
solution may be administered per rectum. On the whole, its efficacy 
in pulmonary hemorrhage is problematical. 

Calcium, Lactate, Acetate, Chloride, etc., are other time-honored rem- 
edies given with a view of increasing the coagulability of the blood 
in doses of 10 to 20 grains repeated four to six times a day. Their 
utility is doubtful; all that may be said about them is that they are 
painless and harmless. 

Camphor. — Several authors have recommended camphorated oil, 
administered hypodermically, in pulmonary hemorrhage. Lunde 1 
reports that the hemorrhage stops. immediately after the injection of 
3 c.c. of camphorated oil. In the experience of the writer, it is not 
superior in its effects to emetin, but it should be used in obstinate 
cases. 

Blood Serum. — The use of blood serum in hemophilia has suggested 
its application in hemoptysis with a view of increasing the coagulability 
of the blood. Horse serum may be used in doses of from 20 to 40 c.c. 
subcutaneously. Inasmuch as, at present diphtheria antitoxin is 
everywhere available, it may be used. But manufacturing chemists 
now have on the market appropriate preparations. It should not be 
used several times at long intervals for fear of anaphylaxis. I have 
tried it several times and was not favorably impressed with it. 

Thromboplastin and Euglobulin, which have been prepared according 
to A. F. Hess's method, and found efficacious when applied directly to 
bleeding surfaces, have been tried by George Mannheimer and Stanley 
L. Wang 2 in the treatment of pulmonary hemorrhage. It appears 
from the published cases that these preparations have no effect on the 
bleeding. 

Venesection. — With a view of producing a rapid fall in the blood- 
pressure, venesection has been used in desperate cases of pulmonary 
hemorrhage. In the days of indiscriminate bleeding, this was one 
of the standard therapeutic measures, 3 but even at present many 

1 Norsk Magazin for Laegevidenskaben, 1918, lxxlx, 1253. 

2 Am. Rev. Tuberc, 1917, i, 469. 

3 According to Sidney Cohan (John Keats, London, 1917, p. 384), John Keats, the 
youthful but consumptive English poet, was bled when he was frightened one night by 
the expectoration of blood. Keats stated that he could not be deceived in the color, 
which indicated to him that it was arterial blood, and that it was surely his death-war-, 
rant. He, however, lived for about twelve XQQuths aiter that pulmonary hemorrhage. 



HEMOPTYSIS 659 

authors recommend it. Bonney recommends it when the blood- 
pressure is abnormally high, even in small initial hemoptysis, and also 
in bronchopneumonia following pulmonary hemorrhage, when the 
right heart is dilated and there are pulmonary edema, cyanosis and 
coma. More recently A. G. Shortle 1 urged this method again in cases 
in which the bleeding is seriously interfering with the functions of 
respiration. "The prompt relief to the impaired respiration is not 
the only benefit rendered in such cases. The coughing and struggling 
for breath, with the coincident inspiring of blood and sputum into 
the air cells is also stopped, and the development of bronchopneumonia 
may be prevented." In persisting hemorrhages it is also indicated, ac- 
cording to Shortle: "It is safer to bleed from the arm than from the 
lung." 

Of course, this is rather heroic treatment, and involves great respon- 
sibility, especially when attending to patients in their homes. But in 
the desperate cases, in which there is evidently nothing to lose, it may 
be given a trial when everything else has failed. 

Diet in Hemoptysis. — In cases of slight hemoptysis with streaky 
sputum, or when a few mouthful s of blood are brought up, the diet 
need not be changed. But in active and profuse hemorrhage all solid 
and hot foods are to be interdicted. Inasmuch as the first indication 
is to reduce the blood-pressure, we must restrict the quantity of 
fluids ingested. Sudden or rapid filling of the bloodvessels with water 
increases the blood-pressure and may lead to an increase in the 
bleeding. In European resorts, where phthisis is treated with mineral 
waters, hemorrhagic cases have been excluded ostensibly for the 
reason that excessive ingestion of water induces hemorrhage. In 
very copious hemorrhages, fluids should be given only for the purpose 
of allaying thirst — a couple of ounces at a time. Swallowing small 
pieces of ice serves this purpose best. Alcohol, coffee and tea, etc., 
should be discarded. Milk, eggs, scraped beef, etc., may be given in 
small quantities at a time. 

Twenty-four hours after the cessation of the bleeding, irrespective 
of the clots expectorated with the sputum, we may begin to feed the 
patient guardedly. The general condition of the patient, as well as 
the concomitant symptoms, should be our guides. A cup of milk every 
hour or two, cream, a raw egg, and some scraped beef may be given. 
On the third day ordinary feeding may be resumed, so that about 
five or six days after the hemorrhage a standard dietary is reached. 

Convalescence. — During convalescence, if there is no fever, or there 
are no other complications, the patient may be permitted to sit up in 
bed, or on a comfortable chair twenty-four hours after the cessation of 
active bleeding. The expectoration of clots, which continues for several 
days, as a rule, should not deter us from allowing the patient to sit up. 
Forty-eight hours after the stoppage of active bleeding I permit my 

1 Tr. Nat. Assn. Study and Prevent, of Tuberc, 1915, xi, 147. 



660 SYMPTOMATIC TREATMENT 

patients to walk around the room. I have not met with a case in which 
walking induced a new attack of hemorrhage. On the other hand, the 
resumption of exercises should be delayed, especially after profuse 
hemorrhages. The patient is more or less exsanguinated and weak. 
He needs rest and good nourishment to recoup. It is best that for two 
or three weeks after such a hemorrhage the patient should keep at 
comparative rest. The cough should be carefully controlled during 
that period and exposure, especially to intense sun rays, avoided. 

Dyspnea. — We have seen that subjective dyspnea is rare in chronic 
phthisis, and that the patients are only rarely short-winded, if at all. 
In some cases this symptom demands treatment. 

Toxic dyspnea, due to progressive disease of the lung, is best treated 
by rest. It is always accompanied by fever, and the treatment directed 
to remove the pyrexia usually helps along in the direction of relieving 
the air hunger. During acute exacerbations in the course of chronic 
phthisis, toxic dyspnea is very frequent and the treatment is clearly 
defined. 

Dyspnea is often due to some preexisting disease. This is the case 
with pulmonary emphysema, asthma, cardiac and renal disease. The 
treatment is that of the underlying pathological condition. In those 
having emphysema, or asthma, the iodides are very often of immense 
help, provided there is no tendency to hemoptysis. For the nocturnal 
attacks of dyspnea, morphin or heroin may have to be given. 

Dyspnea may be due to some acute or subacute complication, 
such as pleurisy, with or without effusion, spontaneous pneumothorax, 
etc. The treatment is considered in the sections dealing with these 
complications. In the terminal stages of the disease the air hunger 
may only be relieved by large doses of morphin or heroin, and no patient 
should be denied these solacing remedies. The dangers of habit 
formation should not be thought of at this stage of the disease. 

Cardiac Weakness. — Patients who suffer from tachycardia or car- 
diac palpitation, permanent or provoked by mild exertion or excite- 
ment, must be kept at perfect rest in bed. Smoking and the consump- 
tion of alcohol and coffee are to be interdicted, and all forms of nervous 
and emotional excitement are to be avoided. At times these cardiac 
disturbances are due to gastric derangement and may call for modi- 
fications in the quantity and quality of the food. 

In many cases, especially in the advanced stages, palpitation is due 
to cardiac displacement, especially in left-sided lesions in which the 
heart is drawn upward and to the left. Rest is the only remedy we 
have for this condition. 

From whatever cause cardiac weakness arises, it may at times 
become acute; collapse is not uncommon after some excitement or 
overexertion. Now and then a patient dies suddenly as a result of 
heart failure. For collapse, hot drinks of whisky, warm applications 
to the extremities, and some stimulants like camphor, strychnin, etc., 
are to be administered hypodermically. 



ANOREXIA 661 

In the far-advanced stages there is acute dyspnea, cyanosis, and 
edema, owing to cardiac failure resulting from the extensive lesion, 
toxemia, etc. These terminal symptoms are treated with digitalis, 
though in my experience this drug has only exceptionally an influence 
on the heart at this stage. In most cases the subjective feeling of weak- 
ness and air hunger are best relieved by liberal doses of morphin or 
heroin. 

Insomnia. — In phthisical patients insomnia may be due to various 
causes, and it is not advisable to resort to soporific medication in every 
case. Rest and fresh air in the sleeping room may induce sleep; 
so may avoidance of a heavy meal late in the evening, a warm bath 
before retiring, etc. These means will suffice in most of incipient 
cases in which the sleeplessness is due to worry on account of the 
seriousness of the ailment. In some of these cases the bromides are 
very useful. 

In incipient cases insomnia may be due to the cough which keeps 
the patient awake, and the indications are those discussed when speak- 
ing of the treatment of cough. When due to digestive disturbances, 
it is to be treated accordingly. In the advanced stages it is often 
due to the fact that the patient is lying at perfect rest during the 
whole day, and sleeps several hours, for an hour or so at a time. The 
patient is then to be kept awake during the day. In some cases 
hypnotic drugs must be given, and of these sulfonal or trional, in 10- 
to 15-grain doses, may be administered; 3 to 6 grains of veronal will 
serve the purpose in some cases. If the treatment has to be prolonged, 
the drugs may have to be alternated. In the far-advanced stages only 
large doses of morphin may give relief. 

Pains in the Chest. — Most of the pains in the chest complained of 
by tuberculous patients may be relieved by the administration of some 
placebo, or the application of a mustard plaster, dry cupping, tincture 
of iodin, etc. In some cases it is necessary to administer some of the 
coal-tar analgesics or salicylates. Small doses of antipyrin, phenacetin, 
pyramidon, etc., with carTein may be given. Sodium salicylate or 
aspirin gives relief in many cases. But on rare occasions we meet 
with patients in whom the pains in the chest are so severe as to require 
the administration of a dose of codein or morphin. When due to 
intercurrent pleurisy, strapping of the chest with adhesive plaster is 
indicated. The pains in the shoulder, often due to diaphragmatic 
pleurisy, which are very acutely felt especially during the night, are 
very difficult to manage. The coal-tar analgesics and the salicylates 
usually give no relief, and often even safe doses of morphin fail. Hot 
applications to the affected part, or, rarely, the actual cautery, may be 
necessary. 

Anorexia.— Many patients have a good appetite; even when the 
fever is comparatively high the desire for food may be retained, 
which is not observed in other febrile diseases. But in others it is 
defective or inadequate to induce them to ingest a sufficient quantity 



662 SYMPTOMATIC TREATMENT 

of food for the replenishment of the inroads on their bodies made by 
the disease. It has been my experience that their number is not very 
large among those who are well instructed along the line of proper 
food and nourishment. 

Medicinal treatment is. not the" first thing to give in anorexia. Out- 
door life, regulated exercises, regularity of meals, etc., suffice in most 
cases to improve the appetite to the desired degree. In many it will 
be found that dietetic errors are at the bottom. The traditional and 
stereotyped advice, "plenty of milk and eggs," given indiscriminately, 
is more responsible for disgust for food than any other single factor. 
Drinking two or even three quarts of milk a day, and swallowing 
six to twelve raw or soft-boiled eggs, overload and often dilate the 
stomach, produce congestion of the liver, and create a disgust for 
all kinds of food. While some patients, who may be considered 
dietetic curiosities, may keep up with such a regime for weeks and 
even gain in weight, in the vast majority the digestive organs revolt, 
the palate loses its taste for food altogether and, coupled with diarrhea 
or constipation, the functions of assimilation fail. 

In this class of patients we may note with satisfaction a remarkable 
change soon after the quantity of milk and eggs is reduced, or they are 
altogether discarded for a time. We must never neglect to tell our 
patients that so long as the appetite and digestion are good, they need 
not make any changes in their accustomed diet, excepting perhaps to 
increase the quantity, which is very desirable. With a variety of food- 
stuffs it is usually easy to consume more than before the onset of the 
disease. Instructions along the lines of good cooking should never be 
neglected. Among the poor and moderately well-to-do it has been my 
habit to send for the mother, wife or sister of the patient and urge her 
to exercise special care in the preparation of the food and to cater to 
the palate of the patient. The person who has prepared food for the 
patient for a long time knows best what he will relish. Of course, the 
teeth are to be examined and repaired in case caries are found, and 
proper instructions as to mastication are to be given. 

In most cases the appetite can be improved by corrections of any 
of the just-mentioned errors without any medication at all. All are 
to be told in plain language that their only chance for recovery lies 
in consuming proper food and plenty of it; that they can best be cured 
through their stomach, and that they must eat even if the desire for 
food is not at its best. This often has the desired effect. When the 
patient finds that with proper food he gains in weight he is encour- 
aged to eat more. The gain in weight is usually seen best during the 
first month or two, but after a considerable increase the gain slackens. 
So long as he holds his own at his former weight, or little above, there 
is nothing to worry about. 

Very frequently superalimentation is the cause of anorexia. In 
these cases it is advisable to try C. V. Spivak's 1 suggestion: The 

1 Colorado Medicine, 1918, xv, 90. 



CONSTIPATION in- 

patient who lacks an appetite is told to omit one, two or more meals 
until the appetite naturally returns. Natural hunger, thus induced, 
at times improves the appetite and relish for food much better than 
any dietetic or medicinal procedure. 

Gastric Disturbances. — In some cases we must resort to medication 
to provoke an appetite. I consider creosote as the drug which acts 
the best. Small or moderate doses of creosote or any of its derivatives 
— creosote carbonate, guaiacol, guaiacol carbonate, etc. — may be 
given and the appetite and digestion promptly improve. In others 
we may give bitter tonics — the tinctures of nux vomica, condurango, 
cinchona, etc. Orexin tannate is also good in 5-grain doses in powder 
or tablet form taken half an hour before meals. When there is diar- 
rhea, this drug is very good. I have used the following with good 
results : 

1$ — Tinct. nucis vomicae 5ij 8.0 

Acid, nitrohydrochlorici dilut 3iij 12.0 

Tinct. gentianse comp 5ij 64.0 

Tinct. cardamomi comp q. s. ad 5iv 120.0 

M. S. — One teaspoonful well diluted in water three times a day before meals. 

The nux vomica may be replaced by condurango, and the nitro- 
hydrochloric acid omitted, in cases in which they are contra-indicated. 
In obstinate cases stomachic medicaments are to be changed often. 

In hyperacidity dietetic changes are to be made according to indi- 
cations, and it is always to be borne in mind that it may be due to 
overfeeding. Often medication is necessary. I have had good results 
with the following: 

1$ — Magnesii oxidi 3iv 16.0 

Sodii bicarbonatis 5j 32.0 

Extracti belladonnae gr. ij 0.13 

M. ft. chart. No. xxiv div. 

S. — One powder three times a day after meals. 

Or the following effervescent powder may be given: 30 grains of 
bicarbonate of sodium in one powder, and 10 grains of tartaric acid 
in another. Each of these is to be dissolved in half a tumbler of water, 
then added one to the other and swallowed during effervescence. 
Some are relieved by a tablet of T }o grain of atropin sulphate given 
after meals. 

Constipation.— Constipation is another of the troubles of the phthis- 
ical which often interferes with the favorable progress of the case. 
It is best combated by proper dietetic measures, especially increasing 
the quantity of fruits and vegetables, fresh and cooked. But mildly 
laxative drugs must >e given in many cases. Before giving them 
we must make sure that it is not one of the anodyne drugs, codein, 
morphin, dionin, etc., which is responsible. Phenolphthalein appears 
to be the best, and 3 to 5 grains may be given, and next to it cascara 
sagrada in appropriate doses. 



664 SYMPTOMATIC TREATMENT 

In the advanced stages, complicated by adhesive peritonitis, when 
diarrhea is apt to alternate with constipation, laxative drugs are to 
be used with caution. They may induce uncontrollable diarrhea. It 
is always better to first try proper changes in the diet, or the effects 
of some special food. Thus, I find that buttermilk will cause a move- 
ment of the bowels better than any medication in some tuberculous 
patients. 

Diarrhea. — We have seen that diarrhea in the tuberculous is not 
always due to ulcerations in the intestines and that the latter may 
exist while the patient is constipated. In many cases the diarrhea is 
due to chronic catarrh of the bowels induced by swallowed sputum 
and the patient is to be warned against this very bad habit. In 
others it is due to consumption of large quantities of raw milk, and 
particularly raw eggs, as has already been shown (see page 228), and 
this must be corrected. 

In case the diarrhea is due to tuberculous ulceration or amyloid 
degeneration of the intestines, it is often very difficult to manage. 
The patient must remain in bed and appropriate changes be made 
in the diet. Fluids in general are to be reduced in quantity, especially 
cold drinks. The great majority of vegetables, salads, fruits — raw or 
cooked — pastries, rye bread, fats and sweets are to be avoided. While 
most patients tolerate milk very well, there are many who do not and, 
in obstinate cases, it is advisable to discard it for a few days and watch 
the effects. Bouillon and soups should be given without the addition 
of vegetables; eggs, butter, scraped or finely minced beef, boiled 
fish and oysters may be allowed, but no lobster. Of the vegetables 
and cereals allowed the following may be mentioned: Rice, sago, 
etc., boiled in milk or served with cream, mashed potatoes, etc. 

In many cases medicinal treatment must be given to control the 
frequent stools. The ancient "styptic" remedies, such as lead acetate, 
iron, alum, etc., are worthless in the vast majority of cases. But the 
modern preparations of tannin, such as tannigen, tannalbin, etc., are 
occasionally of service in large doses, and should be given a trial. The 
subnitrate of bismuth should be given in doses of 10 to 15 grains five 
or six times a day. But in most cases opium must be used, more or 
less. Bismuth or tannigen may be given in powders combined with 
fairly large doses of Dover's powder, or the official tincture of opium 
in 5- to 10-minim doses three or four times a day. 

3— Tannigeni 3iij 12.0 

Bismuthi subnitratis 3vj 24.0 

Resorcinolis gr. ix 0.6 

M. ft. cachet No. xviii. 

S. — One cachet four times a day. 

I£ — Bismuthi subnitratis §j 32.0 

Tinct. opii deodorati 3ij 8.0 

Aquae cinnamoni q. s. ad 5iiv 120.0 

M. S. — One teaspoonful four times a day. 



DIARRHEA 665 

When bismuth subnitrate fails we may try the subgallate in 10- or 
15-grain doses with or without opium. There are, however, many 
cases in which everything, even the administration of heroic doses 
of opium, fails to stop the diarrhea and we must be content with 
relieving the pains. 

D. Mandl has had good results in rebellious diarrhea by the injection 
into a vein in the arm of 5 c.c. of a 5 per cent, solution of calcium 
chlorid. Saxtorph 1 reports encouraging results with this method and 
says that a large proportion of patients are freed from the symptoms 
of intestinal tuberculosis for quite a long time. Recent experience of 
the writer seems to confirm Mandl' s observations. 

Some of these patients complain of tenderness or pain in the abdo- 
men. This is best relieved by hot fomentations. In the later stages, 
when emaciation is extreme, the extremities are to be kept warm and 
the unfortunate patient should not be denied the merciful relief of 
morphin in large doses. 

1 Ugeskrift for Laeger, 1918. lxxx. 1763. 



CHAPTER XLII. 

OPERATIVE TREATMENT— ARTIFICIAL 
PNEUMOTHORAX. 

Historical Note. — Spontaneous pneumothorax has been the most 
dreaded of complications of phthisis and experience has taught that 
the vast majority of patients who suffer from this accident succumb. 
But some have observed that a pneumothorax may be what the 
French call "providential," and exert a rather salutary influence on 
the symptoms of the underlying disease. In fact, as far back as 1822, 
James Carson, 1 a physiologist at Liverpool, suggested the advisa- 
bility of artificially inducing pneumothorax in phthisis for therapeutic 
purposes, and performed some animal experiments with a view of 
working out a suitable technic. In his book on diseases of the chest, 
published in 1837, that acute clinical observer, William Stokes, 2 has 
this to say: "The proper symptoms of phthisis are in many cases 
arrested, and singularly modified, by the occurrence of the new disease 
(pneumothorax) . I have often found that after the first violent symp- 
toms had subsided, the hectic ceased, the phthisical expression dis- 
appeared, the flesh and strength returned; and in this way the patient 
has enjoyed many months of comfortable existence, and was only 
disturbed by dyspnea and the sound of fluctuation on exercise." 
In his book on Diseases of the Lungs, published in 1860, Walter Hayle 
Walshe 3 says: "In some recorded cases of actively advancing phthisis, 
the first sufferings of accidental perforation having passed, it has 
certainly appeared, though the signs of hydropneumothorax remained, 
that the phthisical symptoms themselves underwent improvement. 
But an occurrence so rare gives no warranty for the fanciful proposal 
to treat phthisis by producing artificial pneumothorax." This shows 
clearly that the method was suggested in England long before Forlanini 
had done it in Italy. During the course of the nineteenth century 
many other physicians have reported experiences similar to those of 
Stokes and Walshe just quoted. 

It was, however, C. Forlanini, 4 of Pavia, who first induced a pneumo- 
thorax for therapeutic purposes, and reported his experiences in 1894. 

1 Elasticity of the Lungs, Tr. Roy. Soc, London, 1820; Essays, Physiological and 
Practical, Liverpool, 1822. 

2 Treatise on Diseases of the Chest, New Sydenham edition, p. 455. 

3 Practical Treatise on Diseases of the Lungs, American edition, Philadelphia, I860, 
p. 250. 

4 Gazz. d. osped., 1882, hi, 537, 585, 601, etc.; Gazz. med. di Torino, 1894, lxv, 
381, 401. 



PRINCIPLES UNDERLYING THE TREATMENT 667 

Independently of Forlanini, John B. Murphy, 1 of Chicago, did the 
same in 1898. But for some time no notice was paid to this method 
of treatment until Brauer, Spengler, and some others, took it up in 
Germany. At present it is one of the recognized methods of treat- 
ment of certain cases of pulmonary tuberculosis. That it is a valuable 
method will be appreciated when it is borne in mind that it is mostly 
indicated in cases in which everything else has been tried and found 
wanting; in other words, when there is everything to gain and noth- 
ing to lose. Contrasted with other methods of treatment, which are 
nearly always stated to exercise their alleged curative effects only 
during the incipient stage of the disease, when diagnosis is often 
doubtful and spontaneous cures are not uncommon, it is to be consid- 
ered one of the best therapeutic procedures we have at present for 
the cure of phthisis. 

Principles Underlying the Treatment. — The aim is to introduce into 
the pleural cavity a sterile and harmless material which will collapse 
the lung on the affected, or more affected, side of the chest. The lung 
is thus put at rest and given an opportunity to heal. We have already 
seen that functional rest is as important in phthisis as in other diseases. 
In surgical tuberculosis rest has been more effective as a curative agent 
than all other methods. Rest has also been used with beneficial 
results in other diseases, notably general rest in functional nervous 
diseases, as was worked out by Weir Mitchell; tracheotomy in certain 
laryngeal obstructions, gastroenterostomy in cancer, and especially in 
ulcer of the stomach, enterostomy in certain diseases of the lower 
bowels and rectum, etc. 

The lung is one of the organs of the body which never rests but 
expands and contracts at least 12,000 times per day throughout 
life. With an artificial pneumothorax we can place one lung at rest 
almost as effectively as the splint puts at rest a tuberculous joint, 
without endangering the life of the patient. Moreover, the lung is 
the only organ in the body which is constantly in a state of distention. 
Even after the most forced expiration it does not collapse utterly. 
Any solution in continuity in the pulmonary tissues remains separated 
and there appears to be no tendency to bring about the union of the 
diseased parts, or to facilitate the process of healing, by coaptation. 
Inflating gas into the pleural cavity and collapsing the lung, we achieve 
two objects: The lung is immobilized at its root, and it is compressed 
bv the gas in the pleural cavity and the retraction of its elastic tissues. 
Its volume is greatlv reduced, diseased parts and walls of cavities are 
brought into apposition, so that they may cicatrize by the formation 
of connective tissue. 

Pneumothorax does even more than afford rest to the diseased lung. 
By compression it empties the lung of its contents. The pus and cheesy 
detritus in cavities, the inflammatory exudates in the alveoli and 

i Jour. Am. Med. Assn., 1898, xxi, 151, 208, 281, 341. 



668 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

bronchioles are all squeezed out as from a sponge, removing the main 
source of toxic absorption. It also limits the diseased focus and pre- 
vents its spread, so that the healthy parts of the lung remain so while 
the lesion is in time converted into a cicatrix or is encapsulated. As 
a result of drainage, mixed infection is eliminated and prevented. The 
fact that the air current entering through the trachea cannot circulate 
within the collapsed lung tissues prevents superinfection of healthy 
parts of the organ with emboli of detritus carried from one part to 
another along the bronchial tree, and mixed infection with micro- 
organisms other than tubercle bacilli, which may be brought in with 
the air current, is avoided. 

The circulation of the blood is impeded in the collapsed lung, but 
there occurs a venous or passive hyperemia which is known as an im- 
portant factor in the defence of tissues against tubercle bacilli. The 
comparative protection against tuberculosis enjoyed by cardiacs is 
ascribed by some authors to the venous hyperemia of the lungs. The 
lymph channels of the collapsed lung are compressed, as has been 
shown by Shingu, 1 who subjected animals with induced pneumothorax 
to the inhalation of soot, and at the autopsy found that the collapsed 
lung remained free from soot. Animals were compelled to inhale 
large quantities of soot, and subsequently pneumothorax was induced, 
and when they were finally killed it was found that the free lung was 
darker than the collapsed lung. This tends to show that the circula- 
tion of lymph, which is the main factor in removing inhaled particles 
from the lung, is impeded or arrested because of stasis of lymph in 
the compressed lung. In this manner the absorption of toxins from 
the lesions into the general circulation is impeded or arrested in 
pneumothorax, the clinical phenomena of phthisis, such as fever, 
nightsweats, weakness, etc., are prevented, and the body is thus given 
an opportunity to recuperate. Moreover, the lymph stream being 
unable to carry away bacilli from the lesion, the process is localized 
to the affected areas. These points have been found clinically, at the 
autopsy table, and experimentally. 

Technic. — The technic of the induction of a pneumothorax is simple, 
but not devoid of danger and even fatal accident. The object is to 
inject gas into the pleural cavity and not anywhere else. Forlanini 
developed a technic which is both painless and bloodless. Murphy, 
without knowledge of Forlanini 's work, developed a practically 
similar technic. Brauer was not satisfied that the Forlanini-Murphy 
method is safe and advocated the open incision method. 

The Brauer Method. — This consists in incising the chest wall, dissect- 
ing down to the pleura by cutting through the fascia, and separating 
the intercostal muscles with a blunt instrument in the direction of 
their fibers. When the parietal pleura is exposed, it is punctured 
with a blunt needle or cannula, and the gas is allowed to flow in by 

1 Beitr. z. Klinik d. Tuberkulose, 1908, xi, 1. 



TECHN1C OF ARTIFICIAL PNEUMOTHORAX 



669 



aspiration of the pleural cavity or by pressure, when indicated. This 
method has failed to get many adherents for many reasons. But 
few patients want to submit to a cutting operation. Then there is 
an obvious danger of sepsis which may, of course, be avoided by the 
usual methods. I have found no reason for resorting to the bloody 
operation, and feel confident that if this was the only available method 
of inducing an artificial pneumothorax we should find very few patients 
willing to submit. 




Fig. 92. — Robinson's modification of the Brauer apparatus for inducing pneumothorax. 

Very few now practice this open incision method, and most of those 
who do it make use of it only occasionally when the Forlanini method 
fails because of pleural adhesions. It is, however, a fact that when the 
Forlanini method fails, the open incision almost invariably fails to 
find a non-adherent pleural sac. 

The Forlanini-Murphy Method.— It consists in a simple, bloodless 
puncture of the chest wall with an especially constructed hollow 
needle which is connected with a gas reservoir and a water manometer 
through a T-shaped tube. When the lumen of the needle punctures 
the costal pleura the gas is allowed to flow into the pleural cavity by 
the suction or negative pressure in that cavity, as well as by some 
positive pressure which must, at times, be used at the gas reservoir. 



670 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 



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Fig. 93. — Forlanini-Saugman-Muralt apparatus for the induction of pneumothorax. 
This apparatus consists in the main of two glass tubes, twenty-four and a half inches high 
and about two inches in diameter and a U-shaped manometer tube, the latter filled with an 
alcoholic solution of methylene blue and mounted in the center of the board in front of a 
graduated porcelain scale. The two large tubes are joined by means of rubber tubing 
under the base A. The tube to the left is graduated to 1000 c.c. and the other is plain. 
They are filled with water up to 500 c.c. The graduated tube to the left is filled from the 
tank with the gas to be introduced into the pleural cavity, and the gas displaces the water 
which rises correspondingly in the large plain tube to the right. When filling the appa- 
ratus with gas, the rubber tubing from the tank is to be connected with a rubber gas-bag 
to the opening below the stopcock C. Stopcock D should stand vertically. Stopcock 
C should be turned so as to connect through the filter and into the graduated cylinder. 
Stopcock E on the top of the non-graduated tube should be turned so as to allow the 
air in this tube to escape when the gas forces the water into it. "When the graduated 
cylinder is full of gas, stopcock C should be closed. Funnel F connected with the mano- 
meter tube serves for the filling of the manometer tube to zero with an alcoholic solution 
of methylene blue. The graduated glass tube is connected with the glass tube B which 
js filled with sterilized gauze and serves as a filter., The three-way stopcock C connects 



TECHNIC OF ARTIFICIAL PNEUMOTHORAX 67] 

Simple as this operation appears to be, there are certain difficulties 
to be overcome and dangers to be avoided. The main difficulty is to 
pass the needle as far as the costal pleura, puncture it, and avoid pene- 
trating the visceral pleura and the lung. The dangers are mainly in 
allowing the gas to flow into places other than the pleural cavity, 
especially into a bloodvessel, thus causing gas embolism which, while 
not invariably fatal, yet is sufficiently menacing to be dreaded by all 
who are doing this sort of operation. 

Apparatus. — To avoid this accident, various forms of apparatus 
have been invented. As is usual, they are all based on one main 
principle — the manometer which was introduced by Saugman. Each 
apparatus consists primarily of two graduated bottles connected 
by tubing, one containing the gas to be injected and the other some 
fluid, so that the fluid flows from its container into the other bottle, 
displacing the gas which is sucked or pressed into the pleural cavity 
through a tube and an especially constructed needle. This last-men- 
tioned tube is T-shaped, or provided with a three-way stopcock, of 
which one limb communicates with the gas bottle, the second with the 
needle, and the third with the manometer. At any moment during 
the operation we can open or close the tube leading to the manometer 
or the gas reservoir. 

As has been said, all the instruments for the induction of a pneumo- 
thorax are constructed on this simple principle, but it is amazing how 
some have succeeded in complicating them by adding various attach- 
ments which make them unwieldy, and easily disordered. The uni- 
versal experience that a machine in order to be successful must be of 
the simplest construction consistent with efficiency, holds good here. I 
have been using Forlanini's apparatus as modified by Saugman 1 and 
von Muralt, 2 (Fig. 93) and also the Robinson apparatus (Fig. 92). 

The Function of the Manometer.— The entire safety of the operation 
lies in the manometer which has been called by Edward von Adelung 3 
the heart of the apparatus. While the needle passes through the skin, 
subcutaneous tissue, muscles, and fascia before piercing the costal 
pleura, the manometer records atmospheric pressure, but as soon as 
it enters the pleural cavity the air in the connecting tube becomes 

i Beitr. z. Klinik d. Tuberkulose, 1914, xxxi, 571. 2 Ibid., 1910, xviii, 359. 

3 Jour. Am. Med. Assn., 1914, xlii, 1914. 



DESCRIPTION OF FIG. 93, Continued. 

with the manometer as well as the gas cylinder, thus showing the oscillations when the 
needle is in the pleural cavity. When stopcock D is turned horizontally it permits the 
manometric reading showing the degree of oscillation while the gas is still flowing. After 
the needle has been properly inserted into the pleural cavity and stopcock C turned to 
the graduated tube, the gas will be forced out by the weight of water which is contained 
in the plain tube. When extra pressure is required, a small rubber tube is connected 
with the plain tube, so that the remaining water may be gently forced into the grad- 
uated tube. The manometric scale is divided into 50 centimeters, 25 above and ^5 
below zero, indicating respectively negative and positive pressure. 



672 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

rarefied, because the vacuum in the pleural cavity aspirates its air 
content, and the fluid in the closed limb of the manometer is sucked up 
toward the needle, i. e., from the open into the closed limb, and a dis- 
tinct difference in the levels of the fluid is evident. Moreover, when 
the lumen of the needle is really in the pleural cavity, the respiratory 
movements of the lung are recorded in the manometer which shows 
distinct oscillations of the levels of its fluid. 

This explanation of the work of the manometer, which is found in 
most works on the subject, is unsatisfactory. The fact is that normally 
there is no pleural cavity at all because the parietal and visceral pleura 
lie tightly, one on another; nor can we speak of negative pressure be- 
tween the two pleural sheets because the word " pressure" is here used 
in the sense of gas pressure which can be measured with a manometer ; 
but such a negative pressure does not exist between the two pleural 
sheets. The manometric readings, when the lumen of the needle is in 




Fig. 94. — Brauer-Floyd-Robinson needle. 

the pleura, are better explained by Brauer^Piery, 1 and Moritz 2 in the 
following fashion: The lung must be considered as an organ fixed at 
its root, and kept in a state of equilibrium by the pressure of the atmos- 
pheric air within the air passages, and by the elastic tension of its tissues. 
There is a constant tension of the lung from the roots to the periphery 
at the thoracic walls. The force of this traction is equal to the absolute 
elastic tension in the given direction, minus the atmospheric pressure 
which prevails within the air passages and so prevents its collapse, 
or retraction, from the periphery to the hilus. The intrapleural pres- 
sure, therefore, never differs much from the atmospheric pressure, as 
has been shown by W. Parry Morgan, 3 and in consequence any gas 
drawn into the cavity will not be appreciably rarefied. The volume of 
gas which will have passed from the connecting tube into the pleural 

1 La pratique du pneumothorax artificiel en phthisiotherapie, Paris, 1912. 

2 Munchen. med. Wchnschr., 1914, Ixj, 1321. 

3 Lancet, 1914, ii, 90. 



TECHNIC OF ARTIFICIAL PNEUMOTHORAX 



673 



cavity will be practically equal to the amount of fluid which will have 
passed from the open to the closed limb of the manometer. This 
volume would, when the negative pressure stands at 15 cm. of fluid in 
a manometer tube of 0.3 cm. bore, measure less than 1 c.c. 

This is enough to separate the sheets of the pleura, if there are no 
adhesions. But, owing to the elastic tension of the lung and the 
atmospheric pressure within the air passages, 
there is actually shown a negative pressure in 
the manometer. A little reflection will explain 
why this negative pressure will be stronger dur- 
ing inspiration because of the greater distance 
at that period between the root and the periph- 
ery, and less during expiration. With the in- 
crease in the quantity of gas introduced into 
the pleural cavity the tension of the lung will 
obviously decrease and with it the negative 
pressure, until finally a point is reached when 
the pressure in the gas-containing pleural cavity 
is and later even becomes positive. 

Bearing in mind these simple principles of the 
manometer, we are in a position to guard against 
the most important of the accidents which are 
liable to happen during the operation. In 
patients with pleural cavities free from adhe- 
sions, ordinary and careful attention to the 
manometer will suffice to guard against mishaps. 
The manometer shows conclusively whether the 
lumen of the needle is in the pleural cavity or 
not. It also gives reliable information as to the 
state of the pleural cavity with particular refer- 
ence to adhesions, showing whether they are 
dense and extensive, or of slight extent and 
may be separated and broken up by an increase 
in the intrapleural pressure with the gas. Dur- 
ing the course of the treatment we are able to ascertain, with the 
aid of the manometer, whether the nitrogen has been absorbed and a 
refill is necessary; whether the lung has been completely immobilized 
or has remained expansile. When it is found that the intrapleural 
pressure increases, and this cannot be attributed to excessive gas 
insufflations, it indicates pleural effusion. The difficulties in cases 
with pleural adhesions will be discussed later on. 

The Needle.— Various, some rather complicated, needles have been de- 
vised for this operation. The fact is that any trocar and cannula may 
serve the purpose ; in fact, an ordinary hypodermic needle has been used 
successfully. For the first operation it is, however, best to use one 
with an obturator, which prevents the admission of air, an arm right 
below the obturator, to which the tube leading to the gas bottle and 
43 




Fig. 



95. — Saugman 
needle. 



674 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

manometer is attached. As is stated elsewhere, the needle supplied 
is usually too long; one a little more than one inch in length is best. 
For the first operation the gauge may be over 1 mm., but for subse- 
quent refills, especially in patients showing high suction of the pleura, 
the gauge should be from 0.4 to 0.8 mm. at most. Surgical emphysema 
is often the result of thick needles. 

The Gas Used for Inflation. — Because it was supposed that when 
oxygen is injected into the pleural cavity it is quickly absorbed, and 
that nitrogen will remain within that cavity for a longer time, this 
element was selected and most operators use it. But further experience 
has shown that atmospheric air is just as good. Webb, Gilbert, James 
and Haven, 1 and Tobiesen 2 have shown clinically and experimentally 
that nitrogen has little if any advantage over atmospheric air, 
because in either case diffusion of gases occurs so rapidly that w T ithin 
a few hours the proportion of the two gases, nitrogen and oxygen, is 
about the same. For this reason there is no necessity for using nitro- 
gen. Air does just as well. Nitrogen is rather expensive when bought 
in tanks from manufacturers, and while most of the apparatus for the 
production of pneumothorax is portable, the large iron tank of nitro- 
gen is not easily transported, and atmospheric air is to be given 
preference in private practice. 

The Selection of the Point for Injection. — The first inflation must be 
carefully done, and it is important to select a point to introduce the 
needle where no adhesions are likely to be encountered. Bearing in 
mind the anatomy of the chest and its viscera, it is evident that the ideal 
point is between the anterior and posterior axillary lines, especially at 
the sixth to the ninth intercostal space posteriorly for apical lesions, or 
in the third intercostal space just outside the mammillary line for 
lesions of the lower lobes. Of course, when we are free to choose, areas 
covered with thick muscles, or the thick mammary gland in women, are 
to be avoided. But we are not always free to choose, and any point 
must serve our purpose when the elective places are not available 
because of adhesions. It must also be emphasized that it is very diffi- 
cult, often impossible, to avoid pleural adhesions with all the means 
of diagnosis at present at our command. 

We are .generally guided by the following principles: The chest 
is punctured as far as possible away from the main pulmonary lesion 
because pleural adhesions are most likely to be encountered over 
the diseased lung and, what is more important, while puncturing 
the lung is ordinarily harmless, in such places the needle may, how- 
ever, penetrate a cavity and produce a pyothorax. But adhesions 
are found everywhere, and often where we least expect them. Physical 
diagnosis is apt to prove misleading, and the fluoroscope and skiagraphy 
just as often may fail to reveal them. I have met with cases in which 

1 Arch. Int. Med., 1914, xiv, 883. 2 Brauer's Beitrage, 1911, xxi, 109. 



TECHNIC OF ARTIFICIAL PNEUMOTHORAX 675 

the skiagraph showed all the conventional signs of pleural adhesions 
but puncture revealed a free pleura, and complete collapse was easily- 
obtained with three or four inflations. More often yet the skiagraph 
shows a clear picture and it is concluded that the pleura is free, but 
puncture shows conclusively that there are adhesions. One sign of 
freedom from adhesions should be emphasized: I have invariably 
been able to introduce gas into a pleura over which friction sounds 
were audible during auscultation. On the other hand, feeble breath 
sounds, or complete absence of breath sounds, is in most cases an 
indication of adhesions. 

Forlanini is guided by tidal percussion of the margin of the lung, 
especially at the base. ^Yhen he finds that the base line in the axilla 
shifts between 10 and 12 cm. during extreme inspiration, as compared 
with extreme expiration, he is convinced that the pleura is free. Good 
mobility of the lung margins is the most important sign of freedom 
from pleural adhesions, according to Forlanini, but he adds that 
immobility is not a sure sign of such adhesions and of obliteration of 
the pleural cavity. There are cases of extensive hepatization of the 
lung in which the mobility of the lung margin is defective or absent, 
yet the pleural cavity is free. Robinson and Floyd also consider per- 
cussion the most reliable guide and they say that the area presenting 
a note nearest approaching the normal resonance is most likely to be 
free of adhesions, while von Adelung seeks an area which is resonant 
and yields breath sounds. 

It appears that the most reliable means of ascertaining whether 
or not the pleura is free is the attempt to enter it with the needle 
connected with a manometer. In case the first puncture does not yield 
negative pressure in the manometer — a very frequent occurrence, so 
that when one enters successfully with the first puncture he considers 
himself lucky — another attempt is made at a different point. I have 
made in one case four punctures before succeeding in entering the 
pleural cavity and in another twelve before giving up the case as not 
suitable for the treatment. Forlanini made fifteen punctures in one 
case before he finally succeeded; 

The skin at the site selected for puncture is painted with tincture 
of iodin and the excess is washed away with alcohol. It is then frozen 
with ethyl chloride and an injection of one-third of a grain of novocain 
or cocain in 1 to 2000 adrenalin solution is made. At first the skin is 
infiltrated, then a few drops are injected into the intercostal muscles, 
and finally into the pleura. The latter must not be neglected; it 
appears to be the only known way of preventing pleural shock, of 
which we shall speak later on. 

Thoracocentesis.— The patient is always in the recumbent position 
during the operation, either on an operating table or, preferably, in 
his bed. With a view of widening the intercostal spaces, the hand of 
the side to be operated upon is placed over the head. The selected 



676 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

intercostal space is carefully palpated with the index and middle fingers 
of the left hand to make sure of avoiding a rib when thrusting the 
needle into the chest wall. If a blunt needle is used, the skin is first 
punctured with a tenotome. The needle is inserted and pushed slowly 
forward, passing through the subcutaneous tissue, fascia, and muscles. 
While the latter are passed the needle goes smoothly, but when the 
endothoracic fascia is reached a certain amount of resistance is 
encountered, which is characteristic to the experienced hand. Often 
a snapping sound is audible. A similar but stronger resistance is felt 
when the pleura is passed and it is often difficult to decide with confi- 
dence as to whether it was the fascia or pleura which was punctured. 
"Never move the needle sidewise, for if it should be in the lung the 
latter may be easily torn by it." (Balboni.) The manometer is the 
only means at our command to make sure of where the lumen of 
the needle is. 

How far the needle is to be pushed depends on the thickness of the 
chest wall of the given patient. All efforts are to be made to avoid 
penetrating the lung. While in the vast majority of cases this is 
entirely harmless, on rare occasions it may prove a serious, and even 
a fatal, accident. We may induce a spontaneous pneumothorax, an 
accident which occurs more often than is generally appreciated. 

The usual length of the needle, Floyd's modification of Brauer's, 
is 5 to 6 cm. This is excessive and Saugman's needle, which is only 3 
cm. long, is at present used by me exclusively. Saugman noted in 
100 cases in which he succeeded in inducing pneumothorax the depth 
to which it was necessary to penetrate the chest wall as far as the 
pleura; and in none of them was it deeper than 3 cm.; in the vast 
majority it was only between 1.5 and 2.5 cm.; in some less than 1.5 
and in one even less than 1 cm. 

Technic of Insufflation. — As soon as the lumen of the needle penetrates 
the costal pleura, and there are no adhesions at the point of penetration, 
the tube leading to the manometer is opened and the fluid in the closed 
limb is seen to be sucked up. In some cases the suction is so pro- 
nounced that the fluid shoots up to the upper end of the tube and care 
must be taken that it is not aspirated into the pleura. Usually it is 
elevated between 1 and 6 cm. and oscillates. The patient is told to 
take a deep breath, and it will be observed that during inspiration the 
negative pressure is more pronounced than during expiration. This 
oscillation is the only reliable indication that the lumen of the needle 
is in the pleural cavity, but at times there are observed slight oscilla- 
tions when the needle reaches the costal pleura before puncturing it, 
owing to the respiratory movements of the lung. But these oscilla- 
tions rarely exceed 1 cm. and must not mislead us. Only when the 
negative pressure exceeds 3 cm. may ice venture to let in the gas, and 
beginners should not do it with less than 5 or 6 cm. negative pressure. 

Manometric Hints. — The manometer is to be watched, especially 
during the first operation. The following rules, based on the writings 



TECHNIC OF ARTIFICIAL PNEUMOTHORAX 677 

of Forlanini, Brauer, Saugman, Piery, Balboni, Frederick C. Coley, 1 
and personal experience, are useful guides. 

When the Lumen of the Needle is in the Thoracic Wall. — So long as 
it is outside the endothoracic fascia, the manometer rests at zero. 
When it reaches the endothoracic fascia, feeble oscillations, due to 
respiratory movements of the pleura, may be seen, but they are of 
slight amplitude, between and 3 on each side of the manometer. 
They should not mislead us into the belief that the lumen is in the 
pleural cavity. The fact that there is no negative pressure proves 
this. 

A slight negative pressure during inspiration, becoming less on expira- 
tion, may be produced when the point of the needle is really not in 
the pleural cavity at all, but pushing the parietal pleura before it. 
The indications are clear — the needle is to be pushed ahead guardedly 
until it punctures the parietal pleura. 

After the Needle Passed the Parietal Pleura. — When there are no 
adhesions there is at once seen negative pressure, 5 to 10 cm., and 
distinct respiratory oscillations, higher on the side of the manometer 
which is connected with the needle than on the side .communicating 
with the outer air. If the patient holds his breath during inspiration 
or expiration, or the injection is stopped, the pressure remains negative 
or positive, respectively. 

But at times we meet with this anomalous condition: On passing 
the parietal pleura the fluid in the manometer rises high, showing nega- 
tive pressure of 10 cm. or more, but then it remains stationary. We 
know then that the lumen is in the pleural cavity, and that there are 
no adhesions, but we hesitate to proceed with the injection because 
there are no oscillations. It is clear that the lumen of the needle was 
for a moment between the pleural surfaces, but it has either pushed 
the visceral pleura ahead of it or entered the lung, or it has become 
clogged. In the former case slight withdrawal of the needle will 
reestablish oscillations; in the latter case we put the obturator into 
the lumen of the needle and clear it. 

In case there are dense adhesions and the needle does not enter the 
pleural cavity, the manometer stays at zero and does not oscillate; or 
when slight oscillations are noted they are but 1 or 2 cm. and equal 
on both sides, or slightly positive. 

When there are slight and yielding adhesions, there is feeble negative 
pressure, about 2 to 3 cm., and slight oscillations. Occasionally the 
adhesions yield and the negative pressure, as well as the oscillations, 
suddenly increase. But usually the pressure becomes positive soon 
after the introduction of some gas, indicating that a gas pocket has been 
created. During reinnations, sudden drops in the pressure, due to 
breaking up of adhesions, are more common than during primary 
inflations. 

i Lancet, 1915, ii, 469. 



678 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

When the Lumen of the Needle is in the Lung. — The manometric 
indications will differ according to the structures the needle has pene- 
trated. If it is in consolidated lung tissue there will be no change in 
the level of the fluid in the manometer; it rests at zero. If the lumen 
is in a bronchus or bronchiole, there is usually no negative pressure, 
but there may be slight oscillations of equal excursions. The amplitude 
of the oscillations will depend upon the character of the respiration, 
whether tranquil or labored. When the patient speaks, the respiratory 
effort with a closed glottis produces, while it continues, a greatly 
increased pressure, greater still on coughing. When the patient holds 
his breath, in inspiration or expiration, the manometric readings are 
again zero. 

If after inserting the needle during the first attempt at inflation 
positive pressure is noted during expiration, it is proof that the lumen 
is in the lung or in a bloodvessel. Occasionally it is found that the gas 
flows in freely, but the pressure in the manometer does not ascend. 
This is an indication that gas is escaping as it enters, which could only 
occur when the needle is in a bronchus and never when it is in the 
pleura. "If the key connecting with the nitrogen is quickly opened 
and immediately closed, allowing only a very minute quantity of 
nitrogen to flow in, the manometer then becomes positive, it is 
because the needle is in the lung." (Balboni.) 

// the lumen of the needle is in a bloodvessel there are no oscillations, 
but slight positive pressure may be observed; if some blood enters 
the needle, which is the rule, the pressure will be rising. When with- 
drawing the needle it will be found that it contains blood, and the 
patient may have hemoptysis. 

Injection of the Gas. — With the assurance that the needle is in 
the pleural cavity, the tube leading to the gas reservoir is opened 
and nitrogen allowed to flow in by aspiration, or pressure when 
necessary. After 100 c.c. of gas have entered, the manometer is 
again consulted, and if still showing negative pressure, another 
100 c.c. are allowed to flow in. It has been my habit never to ex- 
ceed 300 c.c. during the first operation, although many do not 
hesitate to introduce two and even three times as much, and some 
even attempt to secure complete collapse of the lung during the first 
operation. Murphy advises the introduction of 200 cubic inches 
(3000 c.c.) at the first operation, while Forlanini now advises only 
200 to 300 c.c. Clinical experience seems to favor smaller quan- 
tities as safer, and many unpleasant, often dangerous, symptoms are 
thus avoided. To change quickly the relations of the thoracic viscera 
is dangerous. Moreover, when adhesions are present, they may be 
forcibly torn apart and cause trouble. When extensive and dense 
adhesions are present, it is often impossible to introduce more than 
100 to 200 c.c. of gas, and the chances of finally securing a complete 
collapse of the lung are rather slim. 

On the completion of the operation the needle is quickly withdrawn 



TECHNIC OF ARTIFICIAL PNEUMOTHORAX 679 

and the index-finger of the left hand placed over the point of the 
puncture and some pressure applied with a view of preventing cuta- 
neous emphysema. Finally the small wound is sealed with some cotton 
and collodion and the patient is warned against coughing, which he is 
to avoid as far as is within his control. I find a dose of morphin or 
codein is useful for this purpose. It has been my rule to send the 
patient to bed for twenty-four hours after the first operation, irre- 
spective of his general condition. 

Method in Urgent Cases. — In urgent cases, as in copious and uncon- 
trollable pulmonary hemorrhages, and when no apparatus and tank of 
nitrogen are at hand, we may resort to Murphy's method which he 
describes as exceedingly simple : " Take an ordinary hypodermic needle, 
rub the sharp point dull on a brick, cover the butt end of the needle, 
with cotton, which will serve as a filter of the air that is to enter, 
then insert the needle into the pleura at the point of election for the 
production of a pneumothorax. The skin should have been painted 
with iodin and punctured with a tenotome. The idea is to let the air 
enter the pleural cavity through a needle, the cotton filtering it as it 
enters, thus producing a pneumothorax. The finger placed over the 
butt end of the needle serves as a valve. As the patient inspires the 
finger is lifted off the needle to allow the air to enter, and on expiration 
the opening is closed with the finger. In that manner you can pump 
the pleural cavity full of air to any desired degree of compression. If 
the patient becomes too cyanotic, or if the breathing is embarrassed, lift 
the finger from the needle and allow a little air to escape. The pro- 
cedure is now reversed. Close the end with the finger on inspiration 
and remove the finger on expiration, so that air will be pumped out 
instead of in." 

Technic of Refilling. — The introduction of a few hundred cubic centi- 
meters of nitrogen does not collapse or immobilize the lung. This 
must be accomplished gradually by further inflations. In cases with 
free pleural this is a simple matter considering that a pocket with gas 
has been already created and the needle can be easily introduced into 
it. For this reason it is best to do the second inflation in the neigh- 
borhood where the first puncture was successfully made, so that it 
enters the gas pocket, and only exceptionally is another place chosen. 
In the latter case we are guided by the same principles as during the 
primary puncture. 

One thing is to be remembered: The manometer is always to be 
consulted before the gas reservoir is opened and, in case no respiratory 
oscillations are seen, the stilette is to be inserted into the needle on the 
assumption that the lumen may be clogged, which is often the case. 
If no oscillations are even then observed, the needle is to be withdrawn 
and reinserted in another place. Accidents have happened during 
later inflations just as during primary operations. 

The quantity of nitrogen introduced during refills depends on the 
case. My way has been to introduce between 300 and 600 c.c. at the 



680 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

second and 800 to 1200 at the third operation, provided the patient 
bears it well. But when I 'find embarrassment of the circulation, 
dyspnea, or pain in the chest, I proceed slower and am satisfied with 
300 c.c. given every other day until complete collapse is attained in two 
or three weeks. We are also to be guided by the final pressure after 
each inflation. In many cases we get positive pressure after several 
hundred cubic centimeters of nitrogen have been introduced, although 
there is no complete collapse of the lung. We often meet with cases 
in which the gas opens but a small pocket in the pleura and when this 
is filled the negative pressure decreases or vanishes. When oscillations 
are good the pressure may be increased guardedly, consulting the 
manometer after each 50 or 100 c.c. have entered. Saugman, whose 
experience is unexcelled, found that if the gas does not pass with 10 
to 15 cm. water pressure the case may be given up, because higher 
pressure will meet with failure. 

At times it is noted that during a refill the pressure suddenly sinks. 
This is an indication that some adhesions have yielded or, which is 
fortunately exceedingly rare, that the lung has ruptured and the gas 
escapes from the pleura into a bronchus. This may occur when the 
nitrogen is introduced under high pressure and the patient coughs 
vigorously. 

My experience coincides with that of Saugman to the effect that it 
is best that, during the first few fillings, the final pressure should not 
exceed 0.5 to 2 or 4 cm. of positive manometric pressure. The condi- 
tion of the patient, as well as his reaction during the succeeding few 
days should, however, be our guide. We must always watch whether 
our aim is not attained with a low pressure, and in many cases 0.5 
to 1 cm. above zero is sufficient. Forcible inflations involve rapid 
dislocation of the mediastinum and injury to the other lung. We must 
bear in mind that it is not always imperative to compress the lung. 
In most cases affording rest to that organ by immobilization is sufficient 
to give relief, and this can be attained without high intrapleural pres- 
sure. But in case the patient is not improving, his cough, temperature, 
expectoration, etc., are not influenced favorably, the pressure is care- 
fully and guardedly increased. A final pressure of 10 to 15 cm. of 
water is too high, though many authors state that they have resorted 
to it in some cases. Of course, as a rule, the gas is quickly absorbed 
and within a few days the pressure drops so that the embarrassment 
of the respiration and circulation is ameliorated. The great problem 
is the cases in which only an incomplete pneumothorax has been 
created and the stiff, unyielding walls of cavities, or dense pleural 
adhesions, prevent the compression of the part of the lung which we 
aim to collapse. Saugman and Forlanini have not hesitated to increase 
the pressure in these cases to 30 and even 40 cm., and they were 
occasionally rewarded by finally attaining a complete pneumothorax. 

Frequency of Refilling. — After complete collapse of the lung has 
taken place the frequency of the refillings is diminished. In some 



SYMPTOMS IN ARTIFICIAL PNEUMOTHORAX 681 

patients the gas is absorbed slower than in others and we are unable 
to say in advance who is likely to need frequent refills and who is likely 
to need infrequent refills. It seems that those walking around absorb 
the gas sooner than those who remain in bed. Primarily the guides 
for the necessity for refills are the general condition of the patient 
and secondarily the findings on physical examination. An elevation 
of temperature, if not due to an impending or actual pleural effusion, 
is often removed by a refill. The same is true of cough and expectora- 
tion. In those who have the lung completely collapsed, there is a com- 
plete absence of breath sounds and adventitious sounds; a return of 
these is an indication that refilling is necessary. The fluoroscope is, 
however, the best guide. But I want to repeat that dyspnea and 
tachycardia, which are often caused by excessive pressure in the pleural 
cavity, are to be guarded against. 

Symptoms. — The acute and urgent symptoms of spontaneous 
pneumothorax are never seen in the artificially created pneumothorax, 
excepting, of course, when the lung is penetrated and the spontaneous 
variety complicates matters. The pain, dyspnea, cyanosis and col- 
lapse are never encountered. In fact, the majority of patients who 
have overcome the fear for the operation are ready and well able to 
leave their beds immediately after the operation and attend to their 
affairs. The slight difficulty in breathing, seen in some cases at that 
time, is usually objective, the patient protesting that he feels well 
although he evidently suffers from air hunger of some degree. But 
even this disappears within a couple of days, as has already been men- 
tioned. Only in rare instances, when the gas separates adhesions by 
high pressure, does the patient complain of pain in the chest which 
is, as a rule, trifling. 

In febrile patients the effects of the pneumothorax are usually strik- 
ing, especially when complete collapse of the lung is attained. The 
fever disappears and, in successful cases, does not return unless there 
is some complication. The temperature charts (Fig. 96) distinctly 
show the effects of collapse on the fever. In some cases it is 
noted that the fever increases 1° to 3° F. for twenty-four hours after 
each insufflation (Fig. 97), just as is the case with the reaction after 
an injection of tuberculin. This is probably caused by increased toxic 
absorption, owing to the compression of the diseased lung. In case 
an increase in the temperature, lasting several days, is^ noted during 
the treatment, we may look for some unpleasant complications, espe- 
cially a pleural effusion. When the pneumothorax does not reduce 
the temperature, we may consider the treatment a failure in this 
particular case. With the disappearance of the fever, the nightsweats 
vanish and this gives the patient great relief. 

The appetite improves in successful cases, and with this the lost 
strength is gradually regained, and the languor, which is such a strong 
clinical feature of the disease, is replaced by a feeling of well-being 

It is noteworthy that, in spite of the improvement in the general 



682 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

condition of the patients, the gain in weight is not a constant phenom- 
enon in artificial pneumothorax. So long as the general condition of 
the patient is good, and the loss in weight inconsiderable, it should not 
trouble us. When, however, the loss of weight is considerable and 
general symptoms, such as fever, sweats, anorexia, etc., make their 



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appearance, we may first try to reduce the pressure in the thorax, and 
if this does not ameliorate the condition, the treatment may have to 
be given up. 

Great relief is usually obtained in patients who suffer from severe 
coughing spells which keep them awake during the night. This is 
especially true of unilateral cases in which a large cavity is emptied 
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DATE 


October. 1914 


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Fig. 97. — Showing the influence of therapeutic pneumothorax on the temperature. 



observed that the amount of sputum expectorated is augmented 
because the pressure exerted by the gas empties cavities and bronchi 
of their contents. After the lung has completely collapsed, or the 
cavities have been emptied in partial pneumothorax, the quantity of 
sputum diminishes, and in unilateral cases expectoration ceases 



PHYSICAL SIGNS IN ARTIFICIAL PNEUMOTHORAX 683 

altogether. In many cases tubercle bacilli are not found in the sputum 
after the lung has been compressed for two months. 

More striking than the improvement in the general condition is the 
cessation of hemoptysis when the first inflation is made in a case of 
hemorrhagic phthisis in which the patient is in constant dread lest 
the hemoptysis recur. We can assure him he is safe in this regard. 
In hemoptysis pneumothorax acts as a hemostatic like the tampon in 
uterine hemorrhage. If during the treatment blood-spitting occurs, 
despite the collapse of the lung, we may be satisfied that the blood 
comes from the untreated lung. 

In many, though not in all cases, there occurs some dyspnea during 
the operation or immediately after. But this is, as a rule, transitory. 
In fact, when the dyspnea is due to fever or toxemia it disappears 
after the induction of pneumothorax. If excessive pressure is per- 
mitted to prevail in the treated pleura, dyspnea is likely to occur which 
is usually transitory. The absence of the dyspnea, despite the cutting 
of the breathing area in nearly one-half, is not surprising because, 
in pneumothorax and in pleural effusion, a reduction of 66 per cent, 
of the respiratory area does not materially alter pulmonary ventila- 
tion, nor the chemistry of respiration, provided the patient is at rest. 
It appears that a human being can live on much less than two-fifths 
of the normal breathing area in the lungs. Some years ago S. J. 
Meltzer 1 called attention to the factors of safety in animal structure 
and economy, to the extravagance of Nature in furnishing most 
of the vital organs with a large surplus of tissue above the amount 
absolutely necessary to perform their physiological functions. Life 
may continue even when the greater part of the lung is destroyed, 
provided the disease which caused the destruction is arrested. We 
see that in cases of pneumonia, pleurisy with effusion, etc. In cases 
of pneumothorax J. H. Means and G. M. Balboni 2 found that during 
rest of the patient respiration, gaseous exchange, carbon dioxid tension, 
and the mechanical factors are normal. The ventilation of the lung 
is accomplished almost normally despite the fact that one lung is out 
of commission. It is for this reason that patients with pneumothorax 
are dyspneic only on exertion. 

Physical Signs.— Recalling the physical diagnosis of spontaneous 
pneumothorax as given in text-books, we are surprised that most cases 
of artificial pneumothorax do not show any of the supposedly pathog- 
nomonic signs. Thus, tympany is not a constant sign, and in some 
cases the treated side of the thorax is simply hyperresonant and, in 
contrast with the untreated side, only shows a tympanitic overtone, 
because of the vicarious emphysema in the latter, which is hyper- 
resonant or even tympanitic on percussion. It is hazardous to diagnose 
pneumothorax on signs obtained by percussion alone. The only 
feature that may give a clue is displacement of the heart, especially m 

» Harvey Lectures for 1906-1907, p. 170. 
2 Jour. Exper. Med., 1916, xxiv, 671. 



684 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

cases of left-sided pneumothorax, in which even a small amount of 
gas may shift this organ to the right. 

On auscultation we find in cases with complete collapse of the lung 
total absence of breath sounds, as well as of any rales which may have 
been audible before the gas was. introduced. In these cases we may 
be guided by the auscultatory findings as to the necessity for refilling. 
When the breath sounds return it means that a considerable portion of 
the gas has been absorbed and must be replaced at once. In cases in 
which the lung has been collapsed, but large bronchi have remained 
active, w T e may hear distinct and exquisite amphoric breathing, or 
distinct metallic breath sounds, which shows that the teaching of 
some text-books to the effect that the amphoric phenomena in 
spontaneous pneumothorax are invariably due to bronchopleural 
fistulae is erroneous. They are evidently due to sounds originating in 
the bronchi which reverberate in the air-filled pleural cavity. 

The progress of the pneumothorax can usually be followed by noting 
the increase in the area of the thoracic surface over which there is 
either absence of respiratory sounds or amphoric breathing after each 
filling, until finally the complete lung is collapsed and all breath and 
adventitious sounds disappear. 

Complications. — Xot all cases of induced pneumothorax run a 
smooth course during the period of treatment. Complications may arise 
during the operation or immediately after, and while the patient goes 
around with a collapsed lung. Of the former, collapse, pleural shock, 
or pleural eclampsia, pain in the chest, and subcutaneous emphysema 
are worthy of consideration ; of the latter, pleural effusion and rupture 
of the lung are the most important. 

Pleural Shock. — Pleural shock may be of various degrees. The mild 
forms manifest merely an increase in the rate of the pulse and respira- 
tion, pallor, dyspnea, etc., which pass within a few minutes or an 
hour. I have met with it several times; in one patient it occurred 
consecutively during the first four inflations and I am inclined to 
attribute it in a great measure to his fear for the operation. In one 
of my cases the shock was quite severe, even alarming, yet it passed 
away within half an hour. Several authors have reported fatal cases. 

The etiology, especially of the fatal cases, is not clear. Forlanini, 
Saugman and others are inclined to attribute it to reflex spasm of the 
cerebral or cardiac bloodvessels. It has been observed that thoraco- 
centesis for any purpose may cause collapse or even death on very rare 
occasions. Brauer is inclined to attribute the symptoms of shock to 
gas embolism in most cases and says that the fact that it is usually 
transitory does not exclude gas embolism. But pleural shock may 
occur without any gas inflations. James A. Lyon 1 mentions a case 
occurring while injecting novocain into the pleura. 

That this accident is comparatively rare is evident from Forlanini's 

1 Boston Med. and Surg. Jour., 1914, clxxi, 329. 



COMPLICATIONS IN ARTIFICIAL PNEUMOTHORAX 685 

figures to the effect that operating on 134 patients, not including those 
in whom he failed to produce a pneumothorax, and making more than 
10,000 operations, he met with pleural shock only twelve times. Among 
more than 500 inflations made at the ■Mont efi ore Hospital we observed 
it but twice to be sufficiently severe to cause some alarm. 

Gas Embolism. — When the manometer is not properly consulted, 
it is said that at times even when the most careful technic is followed, 
gas may enter a bloodvessel and be carried to any part of the 
body and produce an embolism. Usually one of the pulmonary veins 
is entered; it is well known that negative pressure prevails in these 
vessels. Brauer maintains that one of the veins around an infil- 
trated area of lung tissue, or of pleural adhesions, may be penetrated by 
the needle and gas introduced into the circulation. The nitrogen is 
carried into the left heart, then into the aorta, whence it may travel 
into the coronary arteries or the cerebral vessels. Experimental 
researches have not been uniformly confirmatory of this theory, and 
clinically the symptoms of embolism have been observed in some cases 
even when no nitrogen was allowed to enter through the needle — 
merely after introducing the needle. 

Wolff-Eisner, 1 while agreeing that in most instances it is due to gas 
embolism, says that there are some in which thrombi are responsible 
for the symptoms observed. They are derived from the vessels around 
or within the pulmonary or pleural lesion, and dislodged by the needle. 
However, it must be emphasized that symptoms of gas embolism are 
not exclusively encountered in the primary operations, but have 
been met with during refills. 

In many cases gas embolism is difficult of diagnosis. The symptoms 
of pleural shock simulate it to a degree as to render the diagnosis doubt- 
ful in many instances. It is, however, to be remembered that pleural 
shock occurs during every operation of a given patient ; in some, until 
they become convinced of the harmlessness of the procedure, while 
gas' embolism occurs but once, and is rarely repeated. It has been 
stated that in gas embolism there may be found gas bubbles in the 
retinal vessels. But this must be very rare, because in some fatal 
cases of gas embolism the autopsy failed to disclose the gas within the 
bloodvessels. 

The symptoms are collapse, rapid pulse, irregularity of respiration, 
numbness, giddiness, inequality of the pupils, hemiplegia, etc. In 
some rare cases death has occurred without warning. I have been 
fortunate in not having met with a single case of this kind in my 
practice. Of course, prophylaxis is to be the chief aim while operating, 
and one who does not permit the gas to flow into the chest without 
considerable oscillations of the manometric column is hardly likely to 
meet with a case. Fatal cases have, however, been met by the best 
and most experienced operators. 

1 Die Prognosenstellung bei der Lungentubevkulose, Berlin, 1914, p. 498. 



686 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

Pains. — Pains in the chest are felt by the patient occasionally during 
the operation. At times, while introducing the needle as far as the 
costal pleura, and before penetrating it, exquisite pains are felt which 
promptly disappear as soon as the pleura is punctured. This can be 
prevented by proper anesthesia of the pleura with novocain or cocain. 
Very often after the introduction of the gas, pains are felt in the chest 
for twenty-four hours, due to breaking up of adhesions, especially 
when high pressure is applied. They are not at all unbearable and need 
no treatment. Abdominal pains may result from lowering of the 
diaphragm by the intrapleural gas pressure, but this is also transitory 
and needs no treatment. 

Spontaneous Pneumothorax. — Spontaneous pneumothorax may occur 
when the needle lacerates the visceral pleura, or when a superficial 
lesion or cavity of the lung breaks through after the pleural sheets are 
separated by the gas. Forlanini has met with 9 cases of this kind. 
Floyd 1 and Webb 2 mention it. Meyer 3 mentions a case in which it 
occurred while preparations were being made for the induction of an 
artificial pneumothorax. Of course, when this complication is due to 
the entry of the needle into a cavity, or even a caseating part of the 
lung, perforation of the lung, with its concomitants, is likely to be the 
result. 

According to W. Parry Morgan, " spontaneous" pneumothorax is 
more often produced while inducing an artificial pneumothorax than is 
generally appreciated. This is confirmed by the occasional cases met 
with in which the treatment is abandoned after a futile attempt to 
introduce gas into the pleura, and a collapsed lung is then discovered. 
Again, a radiogram of the chest taken after the first operation usually 
shows evidence of more gas in the pleural cavity than has been intro- 
duced from the reservoir. While it is common experience of those 
using the method that gas can be detected after 200 to 300 c.c. have 
been introduced, it has been Morgan's experience that if the visceral 
pleura is not injured the gas cannot be detected until considerably 
more than 300 or 400 c.c. have been introduced. He concludes that 
when a pneumothorax is visible in the fluoroscope after introducing 
300 or 400 c.c. of nitrogen, we have justification for the conclusion that 
radiographic demonstration of a pneumothorax after the introduction 
of such a quantity of gas is achieved only by this being largely 
supplemented by leakage from the lung. 

Emphysema. — The infiltration of gas into the subcutaneous tissue 
of the thoracic wall around the point of puncture is very frequently 
observed, especially in those operated upon by the Brauer method. 
In the vast majority of cases it is due to the high pressure of the gas 
in the pleural cavity, supplemented by cough, and the nitrogen works 
its way along the track of the puncture. It is readily recognized by the 

1 Boston Med. and Surg. Jour., 1913, clxix, 713. 

2 Tr. Nat. Assn. Study and Prevent, of Tuberc, 1914, x, 101. 

3 Ibid., p. 112. 



COMPLICATIONS IN ARTIFICIAL PNEUMOTHORAX 687 

crepitation elicited on palpation, and is of little significance — passing 
away spontaneously within three or four days or at most a week, and 
further inflations are not contra-indicated while it is present. It may 
be prevented by using thin needles and warning the patient against 
coughing, or administering some sedative like codein immediately 
after the operation. It has occurred in about one- half of my cases 
after the first or second operation and rarely after later inflations. 

Of more serious import is emphysema of the deeper tissues of the 
thorax which, fortunately, occurs only rarely and may be avoided 
by careful technic. It is usually due to the introduction of nitrogen 
into the subpleural tissue before the lumen of the needle has pene- 
trated the costal pleura. As was shown by Brauer, Spengler, and 
others, deep emphysema may also be due to leakage from the 
pleural cavity through the wound made by the needle, the gas 
being pressed by the intrapleural pressure or the respiratory move- 
ments especially during cough, into the extrapleural tissues. Saug- 
man is of the opinion that this may even occur without excessive 
intrapleural pressure although the latter enhances the chances of its 
occurrence. The gas works its way along the path of the vessels to 
the posterior mediastinum and thence along the vessels and trachea 
up to the neck, where we may discover it by the crepitations along 
its anterior aspect. It is noteworthy that it is often felt earlier on 
the untreated side of the neck, which Saugman believes is due to 
posture. Rarely the emphysema may extend along the vessels to the 
face, shoulder, arm, and forearm. It may be severe enough to cause 
dysphagia and pain wherever it occurs. But the ultimate outcome is 
always favorable — it disappears within a few days or a week. It 
has occurred in several of my cases and, barring the little inconvenience 
it caused them, it was of no significance. Saugman, who had con- 
siderable experience with deep emphysema, states that in the patients 
in whom it occurs there are but few chances of inducing a complete 
pneumothorax because of the gas leakage. 

Abdominal emphysema, which has been described by several authors, 
I have observed but once. It may occur when the needle is inserted 
along the lower margin of the chest and the diaphragm happens 
to be unduly high, which is not unusual in pulmonary tuberculosis. 
The lumen of the needle may then reach the peritoneum, between the 
diaphragm and the stomach or liver. It is to be remembered that 
there also the manometer will show negative pressure, oscillating with 
the respiratory movements. Saugman points out that it is difficult 
to distinguish these oscillations from those seen when the needle is in 
the pleural cavity, but if it is carefully watched it will be observed that 
when the needle is in the pleural cavity the negative pressure is stronger 
during inspiration, and the reverse is true when the lumen of the 
needle is in the peritoneal cavity. In the case that came under my 
observation, the house physician reported to me that in a patient who 
had adhesions of the pleura which prevented me from introducing gas, 



688 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

he succeeded in getting into his pleural cavity about 1000 c.c. of air. 
But the patient stated that he had pain in the abdomen, and that he 
felt as if the air had entered his "stomach." An examination showed 
shat the abdomen was blown up, highly tympanitic on percussion, 
and the radiogram showed distinctly gas in the peritoneal cavity. He 
made an uneventful recovery, the air being absorbed within a few days. 

Pleural Effusions. — The most frequent and serious complication of 
artificial pneumothorax is pleural effusion in the course of the treat- 
ment. Its frequency varies with the different reports by various 
authors. Some report as high as 60 per cent, of cases, while others 
have met with it less frequently. Some are inclined to attribute it to 
"colds" or to "rheumatism," etiological factors which are open to 
question. Others have stated that it is usually due to infection 
during the operation and maintain that when asepsis is rigidly 
observed, effusions are rare, which does not hold, because effusions 
have been met by the most careful of operators. Floyd says 
that where injections are very frequent and small amounts of 
nitrogen are given at a time, it is more likely to occur than where the 
interval is of some duration. Bullock and Twitchell 1 say that it may 
be prevented by using warm nitrogen. Faginoli 2 considers the nitrogen 
as a foreign body which irritates the serous surface of the pleura, 
predisposing it to disease. It becomes a locus minoris resistenim , and 
inflammation occurs more easily than in ordinary cases of phthisis. 
Klemperer's 3 explanation is more plausible: Disease processes which 
reach the surface of the lung and the visceral pleura cause adhesions 
in patients with normally superimposed pleural sheets, but in pneu- 
mothorax with separated pleural sheets exudative inflammations are 
the result. Rupture of adhesions which lay bare tubercular foci in 
the pleura may also be instrumental in infecting the complete serous 
surface. Bullock and Twitchell 4 consider these exudates a response to 
irritation by the foreign body, the gas. "The secretion of a fluid by 
the pleura is as natural a phenomenon as that of tears by the con- 
junctiva. If the tear duct is occluded, the tears will overflow upon the 
cheeks. When the mechanism of the pleura is in perfect working 
order as to secretion and absorption an excess of fluid is never found; 
but we certainly know that as pneumothorax is protracted the absorp- 
tion properties of the pleura become more and more impaired." The 
fact that the fluid usually contains lymphocytes and is pathogenic to 
animals is conclusive proof of the tuberculous origin of these effu- 
sions. 

The diagnosis is difficult at the onset. In most cases there is a rise 
in the temperature, though at times it may pass afebrile; but there is 
no chill. The fever is hectic and may reach 103° F. and higher. There 

1 Am. Jour. Med. So., 1915, cxlix, 848. 

2 Riv. crit, di clin. med., 1912, xiii, 678, 694. 

3 Berl. klin. Wchnschr., 1911, cxlvii, 372. 

4 Am. Jour. Med. Sc, 1915, cxlix, 848. 



COMPLICATIONS. IN ARTIFICIAL PNEUMOTHORAX 689 

is also a rise in the intrapleural pressure which cannot be accounted for 
by the insufflations, and the manometric oscillations are diminished. 
Groco's triangle can be made out when the effusion is considerable, 
though Faginoli says that it is always absent. Small effusions are 
often very difficult to diagnosticate, and even the fluoroscope may fail 
to reveal them. They are especially difficult to discern in radio- 
grams which have been taken with the patient reclining, for obvious 
reasons. When more or less copious, the usual signs of pleural effusion 
are present plus the succussion sound and the splash, which are at 
times annoying to the patient. 

The effects of the effusion depend on whether they are of a toxic 
nature or not. In the former case there is prolonged fever often of a 
hectic type. Simple effusions, as has been pointed out by von Muralt, 
are rather salutary phenomena and may have a good effect on the 
general and local condition of the patient by the antibodies they pro- 
duce. Faginoli does not agree with this view, and says that, in the end, 
effusions interfere more or less with the favorable outcome of the case. 
Saugman also states that in the majority of cases it is a rather dis- 
agreeable complication, which is in agreement with my experience. 
The patients who have had effusions have not done so well as those 
without this complication. 

So long as there is no fever, and no cardiac embarrassment, the 
effusion should not be interfered with, because it keeps the lung 
collapsed, and this is just at what we aim with the treatment. But in 
cases in which the fever is high it may be necessary to withdraw part 
of the fluid and replace it with nitrogen. In some cases I have applied 
autoserotherapy — withdrawing 10 c.c. of fluid and reinjecting it sub- 
cutaneously, and am under the impression that it enhances absorption. 
We must always watch these exudates. In case they are absorbed too 
rapidly, the lung reexpands and may form adhesions, thus preventing 
its further collapse by the gas inflations. I have given a fair trial to 
the various methods of gas replacement which many authors have 
suggested and found them of questionable value. Withdrawing the 
fluid and injecting gas instead, either in one operation or separately, 
has not given me the results claimed by some writers. Inasmuch as 
the fluid soon reaccumulates, the intrapleural pressure soon increases 
enormously, and the patient again suffers from dyspnea, cyanosis, 
etc. In some cases I had to withdraw the fluid or the gas soon after a 
replacement operation. 

Pyothorax.— In a small number of cases the fluid in the pleura 
becomes purulent, and we then deal with a pyopneumothorax. The 
outlook is grave. Some last for some time, but in most the fever, 
emaciation, etc., are instrumental in dragging the patient down hill, 
and, within a few months, he succumbs to exhaustion, amyloid degener- 
ation of the viscera, extrathoracic tuberculous lesions— of the larynx, 
intestines, etc. Operative interference is here of little value, as is 
true of all cases of pus in the pleura in tuberculous individuals. In 
44 



690 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

rare instances the pus finds its way out through a bronchus, and the 
patient recovers after a long and very disagreeable illness. 

Perforation of the Lung. — We have pointed out elsewhere in this 
book that small cavities in the lung are often located subpleurally, 
and that caseation and softening, of the pleura are not exceedingly rare 
in pulmonary tuberculosis. So long as the pleural sheets are in apposi- 
tion, organized adhesions prevent, in most cases, the breaking through 
of these lesions into the pleural cavity. But a pneumothorax, especially 
if the gas in the pleura is not at a high pressure, will favor perforation 
of these lesions with resulting infection of the pleural cavity. In 4 
cases reported by Allen K. Krause the rupture was due to gangrene in 
1, and in the other 3 there was found at the necropsy a greatly thinned 
pleura overlying the cavities, and in the immediate neighborhood 
there were strong adhesions that bound the particular area to the chest 
wall. The weakened pleura gave way to proper strain. In others, as 
I have seen during necropsies, the rupture is due to adhesions tugging 
upon the pleura, especially during cough, overexertion, etc. The tear 
occurs in these cases at the site of the attachment of the tense adhesion. 
In some cases it may be said to be due to direct perforation of the 
visceral pleura with the needle while attempting to fill the pleura. 
This may be prevented by invariably directing the needle vertically 
downward, and not obliquely, so that if the visceral pleura is punctured 
it is not torn. 

Perforation of the lung occurs suddenly. The patient, who may 
have been doing well, is suddenly seized with intense pain in the chest; 
the temperature rises and signs of a pleural effusion soon make their 
appearance. I have had a case in which the perforation occurred during 
a refill and I noted that the intrapleural pressure, as registered by the 
manometer, dropped suddenly. The subsequent course is that of an 
acutely progressive pyopneumothorax. In nearly all cases the rent in 
the visceral pleura remains open indefinitely, and the pleural cavity 
is constantly reinfected from the tuberculous lesion in the lung. In 
many instances the water- whistle sound may be heard owing to .the 
air rushing in during each inspiration through a bronchus which 
reaches into the fluid within the pleura. 

The treatment is purely symptomatic. Even in the cases in which 
the purulent secretions are well drained through the bronchi, recovery 
is unlikely. The various operative procedures which have been sug- 
gested have proved of no real value, though Spengler reports some 
success attained by repeated aspirations of the fluid and a series of 
plastic operations. Prophylaxis is, however, the only rational thing 
to observe. Proper technic in inducing pneumothorax, especially in 
handling the needle, is of prime importance. Those in whom there is 
but partial collapse of the lung should avoid overexertion, because of 
the danger of tugging of adhesions and tearing the lung. Maintaining 
moderate or high intrapleural pressure is another excellent prophy- 
lactic measure, This can be attained by timely refills. 



INDICATIONS FOR ARTIFICIAL PNEUMOTHORAX 691 

Active Lesions in the Untreated Side.— Extension of the disease in 
the other lung is perhaps the most disheartening complication during 
the treatment. It has been stated that it may be caused by an attempt 
to collapse the more affected lung too quickly; the purulent matter 
is squeezed out rapidly, and it travels along the bronchi to the other 
side of the chest, producing pus embolisms. It has also been attributed 
to excessive pressure in the pneumothorax. It has occurred in some 
of my cases and in none could I attribute it to these causes. In 
some of my cases there was a hemorrhage from the untreated lung, 
but it soon ceased. The writer has had cases in which one side 
of the chest was treated by a pneumothorax and the lesion was 
cured, but subsequently a new lesion flared up in the opposite lung, 
which was also treated by a pneumothorax. This indicates that the 
collapse and compression of a lung do not necessarily impair its function 
permanently. 

Indications. — Forlanini at first urged that only far advanced cases 
of phthisis for which everything had already been tried, but no relief 
was obtained, should be given artificial pneumothorax. As a conditio 
sine qua non it was insisted upon that the lesion must be strictly 
unilateral, and that any involvement of the other side of the chest 
is a contra-indication to the treatment. 

Factors Entering into the Selection of Cases. — The Form and Stage 
of the Disease.- — There are numerous cases of phthisis which are doing 
well and even recover, with or without any treatment, medicinal, 
specific, climatic, or institutional, and it is, of course, not advisable 
to subject them to the operation with its potential complications. 
This is true of mild incipient cases and abortive tuberculosis. Fibroid 
phthisis runs an exceedingly chronic course; the pleura is often 
extensively involved, precluding the introduction of gas into the hemi- 
thorax most affected, and cannot be treated by this method. This is 
also true of the most common forms of fibroid phthisis characterized 
by diffuse fibrosis all over both lungs, and it would be sheer folly to 
treat but one side of the chest. On the other hand, in the later stages 
of diffuse fibrosis, when excavations form in one lung, the question of 
pneumothorax is to be considered, provided, of course, that the pleura 
is free from dense and extensive adhesions. 

It is the acute and progressive form of phthisis in which artificial 
pneumothorax finds its best indications and shows the best and most 
striking therapeutic results. In the group of cases known as galloping 
consumption, in which the patient is carried off within three to six 
months by a rapidly progressing infiltration, caseation and excavation, 
there are many who can be saved by the induction of pneumothorax. 
It is fortunate that dense pleural adhesions are exceptional in these 
cases, and a pneumothorax can easily be induced. The results are 
often astonishing— with the collapse of the lung, the tachycardia, 
fever, nightsweats, cough, expectoration, etc., disappear, and within 
a few weeks the patient is reinvigorated and may continue to gain 
in weight and strength indefinitely. 



692 OPERATIVE TREATMENT—ARTIFICIAL PNEUMOTHORAX 

Another group of cases in which artificial pneumothorax renders 
excellent service are those which have recurrent, copious, and uncon- 
trollable hemorrhages. While, when afebrile, the patients are not in 
grave danger, and death due to exsanguination is rare, yet our efforts 
to prevent recurrence of hemorrhage after one has been stopped by 
keeping the patient in bed for several weeks are often futile, and he, 
as well as those around him, is discouraged. I have had some patients 
who had to remain in bed for two or three months with slight, but 
protracted hemorrhages, one following another. With the induction 
of a pneumothorax, provided we succeed in completely collapsing the 
lung, we have an excellent means of controlling the hemorrhage, 
to prevent its recurrence, and in addition, to give the tuberculous 
focus an opportunity to heal. 

Considering that the hemorrhage is stopped by the mechanical 
effect — by compressing the lung, and thus plugging the bleeding vessel, 
I used to fill the pleural cavity with gas during the first inflation ; in 1 
case I thus allowed 2000 c.c. of gas to enter. But further experience 
has taught me that such large quantities are not necessary. In some 
cases the injection of 300 to 500 c.c. of gas sufficed to stop the bleeding, 
and I now am more conservative in this regard. On the next day 
several hundred c.c. of gas are again permitted to enter the pleura, 
and refills are made according to indications. 

It is obvious that only one lung may be compressed while the 
second must be left to carry on the functions of respiration, and that 
it is useless to combat a lesion in one lung while the disease is smoulder- 
ing or progressing in the other. For these reasons it has been found 
advisable to apply pneumothorax only in unilateral cases. But as a 
matter of fact, in more or less advanced phthisis unilateral lesions are 
hardly, if ever, met with. Klemperer says that he hardly knows of a 
case in which only one lung was extensively involved and the other 
remained free from the disease in the anatomical or bacteriological 
sense. Clinical experience is supported in this regard by autopsy 
findings. Inasmuch as strictly incipient cases are not to be treated 
by this method for reasons already stated, it is evident that in nearly 
all cases in which pneumothorax is indicated there will be found signs 
of involvement of both lungs and we must be satisfied with mild or 
moderate lesions in the untreated side. 

In practice we find that in the vast majority of moderately and 
far advanced cases the lesions are extensive and active in one lung, 
while in the opposite there are limited involvement or signs of quies- 
'cent or healed lesions. Though not strictly unilateral, these cases can 
be successfully treated by pneumothorax, if not prevented by pleural 
adhesions. 

It is interesting that careful clinical and pathological observations 
have shown that only exceptionally is the untreated lung unfavorably 
affected. In spite of the increased functional activity because of the 
vicarious work it is compelled to do, the lung usually remains in the 



PLATE XXIV 



Fig. 1 



Fig. 2 




Complete pneumothorax in right pleural 
cavity, but there are several bands of 
adhesions running from the mediastinum 
to the diaphragm. Left lung shows 
moderate peribronchial infiltrations and 
a few calcified glands at the hilus. Lower 
two- thirds markedly emphysematous. 




Spontaneous pneumothorax following 
first inflation in an attempt at creating 
an artificial pneumothorax in left pleura. 
Diffuse peribronchial infiltration through- 
out right lung. Heart dropped, slightly 
displaced to the right. Pleuropericardial 
adhesions on left side. 



Fig. 3 



Fig. 4 




Incomplete pneumothorax in upper 
part of the right pleura. Owing to dense 
adhesions no more gas could be injected 
and the treatment was discontinued. Note 
the stomach at the left diaphragm. 




Narrow strip of pneumothorax in right 
pleura along the axillary and diaphragma- 
tic margins. Small amount of fluid in 
costophrenic sinus. Several cavities in 
right lung; one of the cavities contains 
fluid. Apex fixed by adhesions. Left 
lung shows marked tuberculous changes 
in its upper half. Dark area in midclavi- 
cular region represents a calcified lesion. 



INDICATIONS FOR ARTIFICIAL PNEUMOTHORAX 093 

same condition as it was before the opposite lung was collapsed. The 
vicarious emphysema which is, as a rule, produced, increases its size, 
and dilates the alveoli and bronchioles, thus permitting as much air 
to be passed through as before, when both lungs were active. It is a 
common observation that active lesions in the untreated lung improve 
or heal after a pneumothorax is induced in the more affected side. 
The factors operative in such cases are not well understood. Carpi 1 
has pointed out that amphoric sounds and rales are often alto- 
gether transmitted from the more affected side, and that diagnosis 
is very difficult. On the other hand, the increased blood supply may 
have something to do with it. The diminution in toxic absorption 
from the ulcerating and excavated lung may give the patient a chance 
to recoup his natural reparative forces, unhampered by the toxemia 
from extensive suppurating areas. However, this is not the rule. In 
some, lesions in the untreated lung flare up and extend, as has happened 
in some of my cases; copious hemoptysis even occurred from the 
untreated lung. 

Forlanini and many others have argued that all advanced cases 
should be given an opportunity to benefit by artificial pneumothorax. 
In far-advanced, bilateral, or "hopeless" cases one side is, as a rule, 
extensively involved, while the other side shows only limited involve- 
ment, though the lesion may be evidently active. In such cases it is 
urged that the more affected side should be treated on the principle 
that there is nothing to lose and everything to gain. Forlanini's 
experience has taught him that when the untreated side has but a 
limited, even though active focus, the chances of success are better 
than would be expected a priori. When both sides are extensively 
affected the chances of recovery are slim indeed, but improvement in 
the general condition may be anticipated, and prolongation of life 
is not unlikely. At times, Forlanini says, 'we may be astonished that 
even such patients are cured. In most cases the removal or diminution 
of toxic absorption gives the patient an opportunity to muster his 
natural forces of resistance and comfort, often superior to that 
obtained in operative procedures for incurable cancer of the stomach, 
may be procured. 

There is another important point to be borne in mind: We are not 
always able to ascertain positively whether the lesion in the less 
affected side is active, quiescent, or even healed. Rales and amphoric 
breath sounds heard over a given area of the chest wall are not always 
autochthonous, but may be in fact transmitted by conduction from 
the opposite side, and this is at times very difficult to differentiate, 
as was alreadv mentioned. Indeed, perfect symmetry in location of 
rales, especially on both sides of the spine in the upper part of the 
chest posteriorly, should always excite suspicion that they may be 
transmitted, and on the side on which they are weaker it is probably 

» Gazz. med. ital., 1911, lxii, 461, 473. 



694 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

so. During and after pulmonary hemorrhage also there are often 
heard rales all over the chest which disappear in the unaffected side 
within several days, but when audible they give the impression that 
both lungs are extensively involved. Skiagraphy is of little, if any, 
assistance in clearing up many of these cases. 

Some French and Italian authors have suggested "diagnostic 
pneumothorax" in cases in which we are uncertain whether the disease 
is active in both sides. The more affected pleura is inflated with gas 
and the opposite lung is watched. In cases in which the physical signs 
of disease are of the transmitted kind, they disappear soon after the 
lung is collapsed. But in case they persist in spite of a complete 
pneumothorax and the general condition of the patient is aggravated, 
the pneumothorax is allowed to be absorbed or, in more urgent cases, 
the gas is aspirated and the lung permitted to reexpand. I have 
repeatedly resorted to this procedure and have, in rare instances, been 
rewarded by improving or even arresting the progress of the disease 
in a case which appeared hopeless. 

There are some who believe that even incipient cases ought to 
be treated with pneumothorax. Among these may be mentioned 
Murphy, 1 Lemke, Bullock and Twitchell, Gray, 2 Forlanini, von 
Adelung, Piery, and some others. Murphy and Kreuscher say: "Is 
it well to wait until the outlook is so desolate? Is the lung col- 
lapse such a desperate operation as to be used only as a last resort?" 
With this I am not in agreement. If the treatment lasted only a cer- 
tain and limited time, the patient could be informed of the details 
and given the choice. But, inasmuch as we are not in a position to give 
the patient definite information as to the probable duration of the 
treatment, and a large proportion of these cases recover under the 
old and tried methods, we should not subject mild incipient cases 
to the dangers, complications, and duration of pneumothorax. I 
still hold that only progressive or hopeless cases are to be given this 
treatment. 

Contra-indications. — To some extent the contra-indications have 
already been given while speaking of the indications, but there remain 
yet to be discussed certain conditions which preclude the induction of 
an artificial pneumothorax, mainly those depending on the clinical 
form of the disease, the coexistence of extrathoracic tuberculosis, and 
of other diseases. Because pneumothorax only acts locally on the 
treated lung, acute miliary tuberculosis, in which both lungs are 
usually equally involved, is not suitable for this treatment. Fibroid 
phthisis with extensive pulmonary emphysema is not suitable for this 
mode of treatment, excepting when, in addition to the emphysema, 
there is a localized, suppurating excavation which is the cause of fever, 
sweats, cough, expectoration, etc., undermining the patient. An 
artificial pneumothorax may be applied as a palliative measure. 

1 Interstate Med. Jour., 1914, xxi, 266. 2 Illinois Med. Jour., 1913, xxiv, 201. 



CONTRA-INDICATIONS TO ARTIFICIAL PNEUMOTHORAX 695 

The most important forms of extrathoracic tuberculosis which 
complicate phthisis are laryngeal and intestinal involvement. Clinical 
experience has shown that pneumothorax may relieve these compli- 
cations to an amazing extent. It appears that when the tuberculous 
toxemia, due to an extensive focus in the lung, is removed by a 
pneumothorax, the laryngeal and intestinal lesions often improve, and 
there are even some cases in which complete cure was obtained of 
both the lung condition and the extrathoracic lesions. A. de Gradi, 1 
Zink, 2 von Adelung, and others, have reported such cases, and Forlanini 
speaks of them, though he confesses his inability to explain them. 
Conceding that the chances of cure are remote, laryngeal and intestinal 
complications should not deter us from applying pneumothorax if the 
case is otherwise suitable, on the principle that there is nothing to lose 
and everything to gain. Of course, advanced laryngeal lesions, with 
dysphagia, and intestinal ulceration, peritonitis, and amyloid degen- 
eration of the viscera, are distinct contra- indications to the induction 
of pneumothorax. 

Diseases of the heart, bloodvessels, and kidneys have been found to 
materially lessen the chances of recovery with an artificial pneumo- 
thorax, and are therefore mentioned as contra- indications to the treat- 
ment. They are all accompanied by disturbances of the circulation, 
and the patients do not bear the deprivation of the breathing area of 
a complete lung. Forlanini, however, has found that when compen- 
sation is good, pneumothorax may be induced with some chances of 
success. Some object to the production of a pneumothorax in persons 
over forty years of age. 

Diabetes has not been found to interfere with the successful out- 
come of an artificial pneumothorax, and the same is true of preg- 
nancy. There have been reported several cases in which pneumothorax 
was induced in pregnant women who went on to term, were delivered 
of healthy infants, and continued under the treatment. In one of my 
cases the woman was six months pregnant when a pneumothorax was 
induced. The effect on the lung was excellent, complete collapse 
was attained and the general symptoms completely disappeared. 
The temperature chart (Fig. 98) shows clearly the effect on the fever 
which has been so far permanent for two years. But she miscarried 
four weeks after the first inflation of gas. It is noteworthy that the 
temperature and the general condition of the patient were not 
influenced by the miscarriage. 

Pleural Adhesions.— These are, strictly speaking, not necessarily 
contra-indications to the induction of a pneumothorax, but they are 
hindrances to its successful accomplishment. In many cases no nitro- 
gen at all can be introduced, because of extensive and dense adhesions 
and, after several punctures are made, the case is given up as unsuit- 
able for treatment. Frequently an area is found which is free and 

i Gazz. med.ital., 1910, lxi, 281. 

2 Beitr. z. Klinik d. Tuberkulose, 1913, xxvii, 155. 



696 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 



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some gas is introduced, but further 
attempts to introduce a sufficient 
quantity to completely collapse 
the lung meet with failure. This 
failure may be of various degrees. 
In some, the pleura is free only 
over a small area and a small pocket 
of gas can be made, while the rest 
of the pleura is adherent. No im- 
provement in the condition can be 
expected and the treatment must 
be abandoned. Pleural adhesions 
often interfere with the treatment 
in a peculiar way. The pleura is 
free all over the chest, except its 
upper third, over the tuberculous 
lesion, where it is densely adher- 
ent. There may be a cavity in that 
location surrounded by stiff walls. 
The result is that, while we succeed 
in collapsing the lower two-thirds of 
the lung, the part which is diseased, 
and which we aim mainly at col- 
lapsing in order to expel the pus and 
detritus from the purulent cavity, 
and thus prevent toxic absorption 
and bring about coaptation of its 
wall with a view of giving them an 
opportunity to cicatrize, cannot be 
collapsed, and the disease keeps 
on its usual course. This is notably 
the case with old cavities having 
stiff fibrous walls which refuse to 
yield to the gas pressure. Many 
failures are due to this condition. 
Fig. 3, Plate XXV shows a radio- 
gram of such a case. In spite of 
all efforts to collapse the lung com- 
pletely, the adhesions around the 
lesion prevented the collapse of the 
diseased part of the lung. 

At times the pleural adhesions 
are not very dense; in fact, slight 
adhesions are said to be present 
in practically all advanced cases of 
phthisis, and an increase in the 
pressure while introducing the gas 



PLATE XXV 



Fig. 1 



Fig. 2 




Complete pneumothorax of the left 
pleura. The right lung shows diminished 
aeration owing to fine, nodular infiltra- 
tion and also to engorgement. Medias- 
tinum completely displaced to the right. 




Complete pneumothorax of the left 
pleura with displacement of the heart to 
the right. 



Fig. 3 



Fig. 4 




Darkness of right lung due to intense 
congestion after induction of a pneumo- 
thorax, excepting at the hilus, where it 
is due to enlarged glands and peribron- 
chial infiltrations. One-half of the left 
pleura is rilled with air, but the collapse 
of the lung was not effective in compress- 
ing a cavity with thick walls, situated in 
the first and second interspaces. Medias- 
tinum displaced to the right. 




Pneumothorax localized in upper and 
lower portions of left lung, but separated 
by pleural adhesions at about the fourth 
rib, where also a cavity with dense walls 
is seen. These adhesions have interfered 
with the success of the pneumothorax. 



CONTRA-INDICATIONS TO ARTIFICIAL PNEUMOTHORAX 697 

breaks them up and success is finally attained — the lung is completely 
collapsed. 

The proportion of cases suitable for the treatment is very small 
indeed. Among 210 patients admitted to the Montefiore Home we 
found only 22 which we considered suitable for the treatment. This 
rather high percentage and is partly due to the fact that strong 
efforts were made by me to find suitable patients outside of the insti- 
tution and induce them to enter. Statistics of most writers seem to 
indicate that less than 5 per cent, of all cases that come under their 
observation are suitable for this treatment. Hardly 2 per cent, of the 
cases that came under my observation during the past five years 
could be considered suitable for pneumothorax treatment. Lemke 1 
appears to be the only author whose clinical experience has been to 
the effect that he has had to abandon the operation in but a small 
proportion of the selected cases because of pleural adhesions. Perhaps 
the reason is that he operated on incipient cases. Bernard 2 foimd 
among 628 patients only 22 in whom he thought pneumothorax was 
indicated, and among these he succeeded only in 6 cases in completely 
collapsing the lung, in 11 adhesions prevented the creation of a com- 
plete pneumothorax, and 3 refused to submit to the treatment. J. 
( ourmont fotmd among 352 patients only 31 that were suitable. Among 
110 apparently suitable cases only in 32 per cent, could Zink produce 
complete pulmonary collapse, and in 24 per cent, he failed to enter the 
pleura altogether because of pleural adhesions. 

Saugman fotmd that in 30 per cent, of the selected cases adhesions 
prevented the entry of gas into the pleural cavity. Even with Brauer's 
method, the proportion of failures exceeds 25 per cent. It must, how- 
ever, be mentioned here that while in most cases complete collapse is 
best, a partial pneumothorax at times serves a good purpose, and 
many writers report excellent results when only creating one or more 
gas pockets in the pleura, and in some of my cases the improvement 
was remarkable under such conditions. Von Adelung even practises 
partial inflation of the two pleura? simultaneously in bilateral cases, 
and he says that the results have thus far been apparently beneficial. 
To my mind this improvement can only be seen in chronic cases of 
phthisis, in which the cavities have been surrounded by stiff walls 
of connective tissue, and which do not secrete any more. Exquisite 
amphoric breath sounds are heard over such cavities, but no rales. 
The excavations are not the cause of the general symptoms which 
disable the patient, but the more acute patches of infiltration in other 
parts of the hmg are responsible for the fever, nightsweats, etc. Com- 
pressing these parts we may achieve good results. In these cases we 
hardly ever achieve a cine with pneumothorax., because the cavity 
cannot cicatrize or contract owing to the stiffness of its walls which, 

1 Jour. Am. Med. Assn.. 1S99, xxx, 959, 1023, 1077. . . 

- Le pneumothorax artificieJ dans le trait ement de la tuberculose pulmonale, fans, 
1913. 



698 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

together with the pleural adhesions, prevents its collapse by the gas 
pressure. But they may be greatly relieved by a pneumothorax. 
However, double pneumothorax is a very dangerous affair; I would 
not venture to induce it. We must always bear in mind the possi- 
bility of rupture of the lung, or of simple spontaneous pneumothorax, 
which may occur even when the most skilled operator is in attendance. 

Duration of the Treatment. — The question how long the pneumo- 
thorax must be maintained in order to achieve a cure cannot be 
answered categorically; no rules can be laid down which will apply to 
all cases. In fact, considering that this method of treatment has 
been applied such a short time, there are few who have many cases 
under observation for from six to ten years, and even they have not 
agreed as to the usual duration of treatment of a successful case. 

It appears that we cannot count on less than two years in the most 
favorable cases, although I have had success within one year in several 
cases — the pneumothorax was allowed to be absorbed and there 
occurred no relapse of the disease. But these cases are comparatively 
few. To my mind, the most difficult problem is to determine when 
the healing process has been completed, so that if the lung is permitted 
to reexpand no active lesion will remain to flare up again by the respira- 
tory movements. This, however, is difficult and, I believe, impossible 
to determine with any precision so long as there is complete collapse 
of the lung, and the general condition of the patient is good because of 
the collapse. Moreover, if we allow the pneumothorax to be absorbed 
too early there may not only be a relapse of the disease, but experience 
has shown that the pleural sheets are likely to adhere, and the fibrous 
bands prevent the formation of a new pneumothorax, if we find that 
this is indicated. 

It is for this reason that whenever we decide to discontinue the treat- 
ment we must watch the patient carefully while the gas is slowly being 
absorbed, and if some symptoms appear, such as fever, cough, expectora- 
tion, anorexia, tachycardia, etc., we must at once reinflate the pleura. 
Forlanini says that many patients require a pneumothorax indefinitely, 
which is undoubtedly true, and most authors who have had experience 
with this method of treatment for many years, and had opportunities 
to observe their cases for long periods of time, agree with him. 

Saugman, who has treated numerous cases with artificial pneumo- 
thorax and observed them for many years, says that when only a 
partial pneumothorax has been created which, however, has had a good 
effect on the symptomatology of the disease, the treatment must be 
continued for at least two years, often for a longer period, according 
to clinical indications; in some cases indefinitely. In cases in which 
complete collapse of the lung was attained, we may expect a successful 
termination in one year, and in some acute cases the treatment may 
be discontinued within one year. Forlanini, Brauer, and myself have 
had in some cases good and even permanent results after six months' 
treatment. It is, however, better to continue for at least two years 



RESULTS OF PNEUMOTHORAX TREATMENT 699 

in all cases. In chronic cases we must consider two years as the abso- 
lutely shortest period of treatment, and in doubtful cases it musl be 
prolonged for three and even four years. The inconvenience to the 
patient in having infrequent refills, four to six annually, is trifling 
considering that he ^ can pursue his vocation, compared with the 
hazards of a relapse in case the lung is allowed to reexpand too early. 
It is therefore better to continue the treatment for a year longer than 
to stop one month too early. If the disease is extensive it is advisable 
that the inflations should be continued over long periods of years, 
perhaps indefinitely. 

Results of Pneumothorax Treatment.— We have seen that hardly 5 
per cent, of cases of phthisis are suitable for pneumothorax treatment. 
In other words, even if all the cases subjected to the operation were 
cured, which is not the case, 95 per cent, of the sufferers from this 
disease are not suitable for the treatment. 

In suitable cases, especially those running an acute course, the 
effect is often striking — the fever declines and with it the symptoms 
of toxemia, etc. But in many cases the improvement is not permanent. 
One of the complications, like pleural effusion in more than 50 per cent, 
of these cases, again brings about fever and symptoms of toxemia, 
etc. In many cases we are finally compelled to abandon the treatment 
because after the pleural effusion, adhesions prevent the introduction 
of more gas. In others, a lesion in the untreated side flares up and 
gives trouble, as might be expected. In still others the lung is com- 
pressed all over excepting the upper third, where the main lesion is 
located, because there it is held by some dense pleural adhesions which 
cannot be separated by increased gas pressure. Autopsy experience 
teaches that often such pleural adhesions can hardly be cut with a knife. 

Under the circumstances the number of cases cured by this method 
is rather small. Statistics which can be considered reliable are not 
available, because hardly two authors have reported comparable 
material. Lemke and others treated incipient cases, which should 
not be done. Others treat only advanced strictly unilateral cases; 
still others confine the treatment to cases in which there is nothing 
to lose, etc. 

This should not deter us from applying the treatment in all cases in 
which it is indicated. We must always bear in mind that in " hopeless' ' 
cases an artificial pneumothorax often saves life, gives comfort and in 
some even efficiency, which cannot be obtained by any other method 
of treatment practised at present. All our cancer surgery, of which 
some surgeons speak with justifiable pride, does not give results 
comparable with artificial pneumothorax in hopeless cases of phthisis. 
No surgeon hesitates in performing the operation of gastrostomy for 
cancer of the esophagus or stomach, knowing that in all probability 
the patient will not survive three months. Palliative enterostomies, 
tracheotomies, etc., are performed with confidence that the best is 
done; even when life is not saved, comparative comfort is given 



700 OPERATIVE TREATMENT— ARTIFICIAL PNEUMOTHORAX 

during the last days of life of the unfortunate patient. In hopeless 
cases of phthisis artificial pneumothorax does much more than this 
palliative surgery: it removes the symptoms which make the life of 
the patient miserable — the cough, the expectoration, the fever, the 
nightsweats, anorexia, hemoptysis, etc.; reinvigorates him, and in 
many cases renders him efficient at his calling or even to do some light 
manual labor, irrespective as to whether he is ultimately cured or not. 
The only inconvenience it puts him to is that he must report every 
month or six weeks for a refill, which he knows from personal expe- 
rience is painless and bearable. In some cases artificial pneumothorax 
is more than palliative — it cures the disease radically and should 
therefore be applied in all cases where other methods of treatment 
have been tried but found wanting. Those who have treated many 
cases have seen many who have become self-supporting at manual labor 
while under treatment. M. E. Rist 1 gives the history of a patient 
with an artificial pneumothorax who withstood the hardships of war 
unscathed. 

Other Surgical Operations for Phthisis. — Extrapleural Pneumolysis. 
— Artificial pneumothorax is not the only method of surgical treat- 
ment of pulmonary tuberculosis. There have been suggested opera- 
tions for the release of the compressed apex of the lung by the shortened 
first rib and ossified cartilage (p. 95); also injections of medication 
right into the lesion in the lung. Th. Tuffier, 2 in France, and Baer 3 
and Sauerbruch, 4 in Germany, have developed the operation of extra- 
pleural pneumolysis with a view of compressing the affected area of 
the lung. The object is practically the same as that of artificial 
pneumothorax, but with this operation only the affected part of the 
lung is compressed while the rest of the parenchyma is left physio- 
logically active. It can also be applied in cases in which pneumothorax 
cannot, as when dense pleural adhesions prevent the injection of air 
or nitrogen into the pleura. 

A small piece of rib is resected over the tuberculous lesion, or the 
phthisical cavity which is surrounded by a thick fibrous wall, and an 
adherent pleura which prevent its shrinkage. The lung with both 
sheets of the pleura is then separated from the chest wall between the 
costal pleura and the endothoracic fascia. The lung is then collapsed 
so that the walls of the cavity are brought into apposition. The 
space thus created under the chest wall is filled in with Beck's bismuth 
paste, bismuth paraffin, or plain paraffin; Tuffier uses adipose tissue, 
fresh or preserved. The wound is then closed properly. Xo general 
anesthesia is used, because while squeezing out the secretions of the 
pulmonary cavity the lungs may be flooded, and aspiration pneumonia 
may be the result. But local anesthesia is sufficient according to those 
who practice the operation. . 

1 Presse medicale, 1914, xxii, 692. 

2 Paris medicale, 1914, iv, 231 ; Interstate Med. Jour., 1914, xxi, 259. 

3 Ztschr. f. Tuberkulose, 1914, xxiii, 209. 4 Beitr. z. klin. Chir., 1914, xc, 247. 



PHRENIKOTOMIE 7( ) l 

Tuffier urges this operation even in incipient cases, saying that we 
should not wait in phthisis till a cavity has formed, any more than we 
wait in tuberculous diseases of joints until suppuration or fistula have 
set in. But the modern treatment of tuberculous joint disease is 
rather conservative, and results are obtained which are superior to 
those obtained with operative treatment. It is doubtful whether the 
operation of extrapleural pneumolysis will ever become as popular as 
that of artificial pneumothorax. 

Phrenikotomie. — Another operation which has been suggested for 
the cure of phthisis is resection of the phrenic nerve with a view of 
procuring rest of the lower part of the lung by paralysis of the dia- 
phragm on the affected side. F. Sauerbruch 1 and Stuertz have done 
this operation in Europe and Ralph C. Matson and Marr Bisaillon 2 
have reported 2 cases in this country. It appears from the few cases 
reported that the operation is of no therapeutic value, if only because 
the diaphragm remains mobile with the respiratory movements after 
the operation. 

More recently Warstat 3 achieved immobilization of the tuberculous 
lung by excision of the intercostal nerves. He argues that phreni- 
kotomie only immobilizes the diaphragm and restricts the motion of 
the lower lobe of the lung, while the tuberculous process is almost 
invariably in the upper lobe. Cutting the nerve distal from the dorsal 
root from the second to the eleventh, inclusive, he succeeded in immo- 
bilizing the upper lobe of the lung. In animals he found that a few 
weeks or months after the operation the upper part of the lung was 
reduced in size and solid in consistency. In two patients in whom he 
thus operated he noted an unmistakable arrest of the disease. 

All these operations and many more have been suggested and even 
performed in isolated cases, may be attractive to the courageous 
surgeon, but they will appeal to the average medical man only in 
exceptional cases. Very few patients will submit to them. 

1 Miinchen. med. Wchnschr., 1913, lx, 625. 

2 Tr. Nat. Assn. Study and Prevent. Tuberc, 1915, xi, 183. 
3 Deutsch. Ztschr. f. Chir., 1916, cxxxviii, 437. 



CHAPTER XLIII. 

GENERAL TREATMENT OF THE VARIOUS FORMS 
OF PULMONARY TUBERCULOSIS. 

Incipient Phthisis. — The treatment of the early stage of phthisis, 
immediately after its recognition, varies with the intensity of the 
clinical manifestations of the disease. We have shown that a large 
proportion of cases manifest a strong tendency to spontaneous cure; 
the disease is "aborted" within a few months. These patients need 
no treatment beyond stopping work, keeping regular hours, increas- 
ing the quantity of food ingested, etc. A stay in the country for a 
month or two is even better. In most cases of this type institutional 
treatment is not advisable; in fact, I have seen some who were decid- 
edly harmed by a stay in a sanatorium, where they were trained into 
carefully studying their disease, and impressed with the dangers of 
slight fever, fatigue, etc. Some have not been as industrious after the 
"cure" as before, though their state of health left little to be desired. 
With workmen having dependent families this is an important point. 

It is different with patients in whom the disease manifests a 
tendency to acute progress; who have fever, nightsweats, cough, 
anorexia, emaciation, etc. These are to be given complete rest of 
mind and body until the acute symptoms are relieved. The best way 
of attaining this depends on the financial resources of the patient. 
The well-to-do may be treated at home, or sent to private sanatoriums. 
The results in either case will be the same in the vast majority of 
cases. Under no circumstances, however, should a patient with pyrexia 
be sent to the country, unless he can afford to take along a well- 
trained nurse, and will have competent medical advice. Febrile 
patients who cannot satisfy these two requirements are best treated 
at home, even if the home is only half-way satisfactory. 

The principles of the rest cure, as well as of the treatment of pyrexia, 
have been given in detail elsewhere. Patients who cannot be managed 
at home along these lines should be sent to sanatoriums. 

Patients with limited means should invariably be sent to institu- 
tions for the first few months of the disease, unless they can be moved 
into good homes where they may have appropriate rooms for them- 
selves to carry out the rest and open-air treatment. But after remain- 
ing in the institutions for the period of pyrexia, they may return home 
where they may be cared for just as well as, and at less cost than, in 
the sanatoriums. Those who have no relatives or friends able and 
willing to give them a proper home should remain in the institutions 



ADVANCED PHTHISIS Tol] 

until the arrest of the disease is assured. As was already stated in 
Chapter XXXVII, the results are the same with home or institutional 
treatment, if the same amount of money is spent upon the patient in 
either case. 

Reasonable patients, running only a subfebrile temperature, may be 
sent to the country for the first few months of the disease. Many 
improve to an astonishing degree, and are cured if the disease is of 
the milder or abortive variety. All patients should be sent out of town , 
preferably to the mountains, if there are no contra-indications, for 
the hot summer months. During the winter most phthisical patients 
do well in the city. 

The dietetics of phthisis have already been detailed in Chapter 
XXXVIII. But it should again be emphasized that patients with a 
good appetite and digestion need no special diet, except that they 
should eat more than they had been accustomed to before the onset 
of the disease. In many cases an increase in the quantity of proteins 
and fats is desirable. Those with anorexia and indigestion are to be 
treated for these conditions, because good gastrointestinal functions 
are the best assets of the phthisical patient. A poor appetite, if not 
improved by open-air treatment, should be stimulated with some of 
the stomachic bitters; creosote in small doses is even better for this 
purpose in many cases. For indigestion appropriate dietetic and 
medicinal treatment is to be instituted. 

In the vast majority of cases medicinal treatment is not necessary 
in incipient phthisis, unless it is for the relief of annoying symptoms. 
Cough may be controlled by the administration of creosote in moderate 
doses. In rare cases sedatives — codein, heroin, dionin, etc. — must be 
given in accordance with the indications discussed in Chapter XXXIX. 
Anemia is to be treated with iron and arsenic. In fact, most patients 
treated at home should be given some medication, even if it is only a 
placebo, and for its psychic effect alone. But there is no doutrt that 
ichthyol, creosote and arsenic, given intelligently, exert a good influ- 
ence on the course of the disease. 

The treatment of complications and special symptoms, such as 
hemoptysis, nightsweats, emaciation, etc., has been discussed else- 
where. 

Most patients in the incipient stage of the disease do well under the 
mode of treatment just outlined. Many will recover within a few 
months; in a large proportion the disease will be arrested, but they 
are liable to suffer from relapses sooner or later. In many the dis- 
ease will continue its onward march, irrespective of the treatment 
applied. We then have the so-called advanced stage. 

Advanced Phthisis.— The zeal displayed by medical men during 
recent vears to discover and treat early cases has resulted in neglect of 
those in whom the lesion has advanced beyond the stage which by 
common consent is called incipient. Hospital wards for advanced 
phthisis are often attended in a haphazard fashion, and the patients 



704 TREATMENT OF VARIOUS FORMS OF TUBERCULOSIS 

are discouraged to a pitiable extent. Patients in the advanced stages 
are usually told by their medical advisers to go to some distant 
climatic resort, irrespective of their condition. This is all wrong. 
There is as much hope for the average patient in the moderately 
advanced stage as for a large proportion of incipient patients. Indeed, 
we have already emphasized the fact that the prognosis in advanced 
phthisis depends less on the age and extent of the lesion than on the 
acuteness and activity of the process. 

A patient with an advanced, especially cavitary lesion, owing to 
the fact that he has survived the incipient stage, proves that he has a 
certain but variable amount of inherent resistance against the 
ravages of phthisis. It is our aim to preserve, or rather to increase, 
this power of resistance. This can only be done by proper regulation 
of diet, rest, and exercise, and by avoiding indiscretions which are liable 
to produce acute exacerbations of the tuberculous process. 

We therefore regulate the diet of the patient in such a manner 
that he will not lack in assimilable nourishment (see p. 608). The 
question of rest and exercise is regulated under the guidance of the 
thermometer and the pulse-rate. In hopeful cases all efforts are to 
be directed at avoiding febrile exacerbations, or rendering them short 
lived if they occur. Many of the afebrile patients may make them- 
selves useful in some direction. Some may even work at their occu- 
pations, provided we find that they are not harmed by activity. The 
fact that one has cavities in his lung does not mean that he is disabled. 
Patients engaged in vocations involving no undue muscular exertion 
may be very efficient. All should do something when strong enough 
to do it, but must cease all activities as soon as they feel fatigued, 
have fever, a rapid pulse, dyspnea, etc. This policy has during recent 
years been adopted in all the enlightened institutions for the care of the 
tuberculous, and the patients have benefited much more than by the 
previous routine rest treatment, carried out indiscriminately. 

The diet in advanced phthisis is to be nutritious and of a character 
that will not overtax the digestive organs. At the least indication 
of indigestion, the diet should be appropriately corrected, because, 
next to fever, indigestion is most liable to hurt the patient irreparably. 
Those manifesting a tendency to obesity, and they are not so infre- 
quent as is commonly believed, should restrict the ingestion of fats 
and carbohydrates. A fat consumptive is often more miserable than 
a lean one. 

Medicinal Treatment. — The average patient is not satisfied with 
hygienic and dietetic treatment, and when no medicinal substances are 
administered he is apt to be led to the belief that there is no remedy 
for him. But there are drugs which have a beneficial influence on the 
course of the disease, as was shown elsewhere (Chapter XXXIX), and 
medication should be administered. Considering that the patient will 
have to be kept under control for months, it is often difficult to allay 
his apprehensions and retain his confidence until the termination of 



MEDICINAL TREATMENT 705 

the case. It is also a fact, to which we have already alluded, that 
while many remedies have an excellent influence on the disease or the 
patient, they retain their potency for but a short time, as a rule. The 
same is true of climatic resorts and of institutions. The patients gab 
best during the first two or three months' treatment. 

For these reasons medication must often be changed. Renon's 
suggestion may be followed: The patient is given a course of several 
weeks with a certain remedy, and then it is changed for another 
medicament administered for several weeks. The results are often 
remarkable : There are gains in general health, the lesion in the lung 
shows signs of cicatrization, and the patient is encouraged. We may 
thus achieve the same results as with tuberculin without incurring 
the hazards of this dangerous preparation. A good method is to begin 
with ichthyol, administered as directed in Chapter XXXIX, for four or 
six weeks; or, if the patient thrives on it, it may be continued longer. 
For a week or two it is given in solution; for another fortnight in 
capsules, etc. Then we may give him creosote, or one of its derivatives 
— creosote or guaiacol carbonate, combined with arsenic, for several 
weeks. These substances may be given in mixtures, pills, globules, 
capsules, or by inhalation, as suggested by Beverly Robinson (see p. 
625). Arsenic may be combined with creosote, or given alone in 
the form of Fowler's solution, or in pill form. Of course, if there is 
a tendency to hemoptysis neither the creosote nor the arsenic is to 
be given. The glycerophosphates are also beneficial, and may be given 
in appropriate doses. They exert an excellent influence on the tuber- 
culous process, promote nutrition, improve the blood picture, etc. 

Medication should be discontinued as soon as there is pyrexia, 
though when the temperature is below 100° F. medication may, and 
should, be given. 

In addition to the above, there is to be given medication according 
to indications as revealed by the symptoms. The anorexia, night- 
sweats, constipation, diarrhea, etc., call for certain medicinal treatment 
which has already been discussed under symptomatic treatment. 

In this manner the average tuberculous patient may get along very 
well for years. Some have very long periods of quiescence, and are 
only rarely laid up with acute exacerbations which need special treat- 
ment, as any acute condition. But they soon recuperate, as a rule, 
and again feel well for a variable period. While many survive acute 
exacerbations occurring at infrequent intervals, provided proper 
treatment is promptly instituted, in most of the chronic cases one of 
these acute exacerbations finally ends fatally. Many succumb to 
intercurrent diseases. These periods of quiescence may be obtained 
by judicious home treatment just as well as by institutional treatment, 
unless we are prepared to keep patients in sanatoriums for many years, 
irrespective of the activity of the disease. _ - 

Cases manifesting a tendency to progression, with acute or sub- 
acute symptoms and unilateral lesions, should be treated with artificial 
45 



706 TREATMENT OF VARIOUS FORMS OF TUBERCULOSIS 

pneumothorax. It offers immediate relief of the symptoms, and shows 
more striking and lasting results than any other mode of treatment of 
active and progressive phthisis. Many of the less acute cases are 
also proper subjects for pneumothorax. The indications and contra- 
indications are discussed in Chapter XLII. 

Some cases show activity of the process despite the careful treatment. 
All efforts at raising the resisting forces are unavailing, and the disease 
progresses to a more or less speedy termination. All we can do is to 
apply symptomatic treatment, and to render the last weeks or days 
bearable and painless. The solacing effects of the derivatives of opium 
should not be denied these unfortunates. It is, however, one of the 
most common mistakes to send these patients to the country or to 
sanatoriums. If such a patient has a home in which there are no 
infants, he may remain there. If his financial resources are limited, 
the proper place is a hospital for consumptives. We are at times 
surprised that under proper care even the most desperate case recu- 
perates, and within a few months returns greatly improved. Rarely, 
they even regain a capacity for working. 

Treatment of Convalescent and Arrested Cases. — A large propor- 
tion of tuberculous patients in the advanced stages of the disease 
improve to an extent as to become useful at their respective occupa- 
tions, although they have not been cured. They cough, expectorate, 
at times the sputum no longer contains any more tubercle bacilli, are 
more or less emaciated, but they have no fever, no tachycardia, etc. 
Physical exploration of the chest shows that there are cavities in 
the lungs, some displacements of the thoracic viscera, etc. Many of 
these are well able to take care of themselves, and even to be efficient 
at some easy occupation. Under proper medical supervision they may 
keep on in this condition for years, even for their natural lives. It is 
very important that these patients have some occupations, otherwise 
they are liable to brood over their condition and become actual hypo- 
chondriacs. The dependent ones are liable to intrench themselves in 
hospitals, and stay there indefinitely; when discharged, they soon seek 
admission to another one. They are very costly to the community, 
as well as to those depending on them. The fact that one has a cavity 
in the lungs does not mean that he is disabled from working any more 
than one who has a chronic fistula or sinus in another part of the body. 
It is the intensity of the constitutional symptoms which should be the 
guide in these matter^, and not the findings on physical exploration 
of the chest. 

Once one has suffered from chronic phthisis of some duration, 
he is never cured in the anatomical sense; he is always in danger of 
a relapse. He should be impressed with the fact that all that was 
attained was an arrest of the process, and that there may be at any 
time a recrudescence of the disease with even greater vigor than the 
former attack. These arrested cases should remain under medical 
supervision for several years, and examined periodically; first fre- 



FIBROID PHTHISIS 707 

quently, then at less frequent intervals, so that ary tendency to a 
relapse may be checked early by proper treatment. While all efforts 
are to be directed toward prevention of excessive introspection and 
hypochondriasis, yet patients with arrested disease should be instructed 
as to the significance of certain symptoms, such as cough, fever, night- 
sweats, loss of weight, etc. During intercurrent diseases, especially 
catarrhal conditions of the upper respiratory passages and influenza, 
they are to drop all work and take a complete rest. 

A patient with arrested disease should live in a healthy part of the 
city, in a good home, and sleep in a room with open windows. He 
may engage in his former occupation, excepting the dangerous ones, 
but the workshop must be of the modern and sanitary type, with 
good ventilation, etc. When possible, workmen should become 
gardeners, conductors, watchmen, chauffeurs, letter carriers, etc. 
When feasible, it is advisable that they take up farming. Well-to-do 
patients may move out of the city and settle for life in the country. 
Others may live in the suburbs, or in any country place where they can 
find suitable employment. Those who remain in the city should avoid 
all indiscretions. The questions of marriage, pregnancy, and lactation 
have already been discussed. 

Acute Phthisis. — The acute forms of phthisis are to be treated 
symptomatically, according to indications, so long as we have no 
specific for tuberculosis. In the pulmonary type of acute miliary 
tuberculosis careful hygienic and dietetic treatment is indicated. 
The nursing is of special importance, if we are to make the last days 
of the patient more or less comfortable. The treatment is the same 
as of any other acute or malignant infectious disease. 

Acute pneumonic phthisis is not invariably fatal; often the patient 
passes the acute stage and becomes a chronic consumptive, and the 
treatment is then the same as that given above for chronic phthisis. 

During the acute stage the patient is to be kept in bed, given food 
suitable for a febrile case, and the indications are otherwise met as they 
arise. If the acuteness of the process abates, the patient remaining 
with an active cavity, climatic treatment may be tried. Some of these 
patients do very well when removed from home to some place in the 
country, irrespective of its location or altitude. But they usually need 
a nurse or an attendant. The practice of sending such patients to 
shift for themselves in the country cannot be too severely censured. 
It is unfortunate that public sanatoriums do not admit this class of 
cases. 

Fibroid Phthisis.— The patient may feel well and be efficient at 
his occupation for many years, and the treatment at this period is 
purely symptomatic. It is, however, imperative to impress on him 
that overexertion and indiscretions are apt to activate the process. 

Many patients with fibroid phthisis are well nourished during the 
latent or quiescent stage of the disease and need no special dietetic 
instructions. But we often meet with persons suffering from active 



708 TREATMENT OF VARIOUS FORMS OF TUBERCULOSIS 

or quiescent fibroid phthisis who suffer from obesity. The dyspnea, 
which is a marked symptom in this disease, is more severe in the fat 
consumptive, and it is advisable to arrange the diet so that the patient 
does not gain in weight excessively. Exceptionally, it is even neces- 
sary^ to reduce the amount of carbohydrates and fats with a view 
of reducing the weight of the patient. In my experience lean, even 
emaciated, individuals suffering from fibroid phthisis are more com- 
fortable and live longer than those who are obese. 

In many cases the iodides are very good. The dyspnea is very often 
relieved, expectoration is facilitated, and the general condition of the 
patient improves by the administration for several months of potas- 
sium iodide, or some of the newer albuminate compounds of iodin. 
But this remedy should not be given during febrile attacks, which are 
not frequent in this disease. When fever appears and is persistent, 
the disease differs but little from common chronic phthisis. Those 
who are subject to hemoptysis, and many fibroid patients suffer from 
recurrent hemoptysis of varying severity, should not be given any 
iodides. It should be discontinued immediately at the appearance of 
streaky sputum. In many cases with profuse expectoration, creosote 
gives relief. 

When signs of asystole make their appearance, with dyspnea, 
edema, etc., appropriate doses of digitalis, strophanthus, etc., should 
be administered. 

Fibroid patients should take frequent vacations. The mountains 
are not suitable for them because these patients are more short-winded 
the higher the altitude. It is best to send them to the plains or the 
sea coast. Many do very well indeed in a desert climate, provided 
they can adapt themselves to the surroundings, or "rough it." 

In the later stages, when fever, nightsweats, cough, anorexia, etc. 
ensue, the case is one of advanced chronic phthisis, and is to be treated 
accordingly. 

Pulmonary Tuberculosis in Children. — The acute types of tubercu- 
losis in infants are hopeless, and the treatment is purely symptomatic. 
The infant is to be cared for as a case of pneumonia at that age. The 
only useful thing we can do for infants less than one year old is to 
prevent infection with tubercle bacilli. Once this has occurred, the 
prognosis is very unfavorable. 

We have seen that chronic pulmonary tuberculosis of the type 
common in adults is practically unknown among children under ten 
years of age. In them the disease manifests itself as hematogenic, 
affecting the glands, bones, and joints, and is then the province of 
the surgeon, though it appears from all available data that hygienic 
and dietetic treatment has achieved better results than the knife in 
these cases. The physician encounters in children disease of the 
tracheobronchial glands. Considering that death due to this disease 
is very rare, it is clear that it is bearable by most children. The 
only problem is whether they are all destined to develop phthisis 



PULMONARY TUBERCULOSIS IN CHILDREN 709 

when reaching the age of adolescence or later. This has not yet been 
solved to the satisfaction of all who are entitled to judge. 

The treatment of tracheobronchial adenopathy aims at assisting 
Nature in its efforts to preserve the child. This can best be achieved by 
doing away, as far as possible, with the unnatural method of raising 
children. Growing children should not be kept indoors the greater 
part of the day and night, but should be urged to indulge in outdoor 
exercises and games. Especially is outdoor life imperative when a 
child shows signs of tuberculous infection or of tracheobronchial 
adenopathy. These children should spend the greater part of the day 
outdoors, and sleep in rooms with open windows. If they can be 
raised in the country it is much better. But in every city, excepting 
the parts known as the "shuns," children may enjoy outdoor life and 
benefit by it. 

It must be borne in mind that children are easily adaptable to life 
in cold air, and most of them can run around the street with scanty 
clothing during very cold days and derive great benefit. They may 
also be given cold spongings followed by friction with a rough towel 
every morning, and thus "hardened." Only in this manner can 
"colds" be prevented in children. Harmless in themselves, colds 
may, in children with tuberculous glands in the chest, activate the 
tuberculous process and favor an acute exacerbation of the dormant 
tuberculous lesion. 

The ideal treatment of tuberculous children is to raise them all in 
the country. But like all ideals, it is only attainable by the favored 
few. The vast majority of infected children have to be raised in 
cities, for obvious reasons. But society, which is largely responsible 
for the conditions favoring tuberculous infection, can do a great deal 
toward saving these children and raising them toward healthy man- 
hood and womanhood, by providing vacations for them once or twice 
annually, so that they may recuperate their vanishing forces and 
acquire resistance against the extension of the tuberculous process. 
In New York City this is done for a limited number of children derived 
from tuberculous stock by the Preventorium. In other cities in this 
country similar efforts have been made. But not all that need these 
vacations, proper food, and exercises are accommodated in any city. 

If the parents of a child with tracheobronchial adenopathy can 
afford it they should move to the country or to a suburb. In some 
cases it is feasible to send the child to be raised outside of the city lines. 
Many authorities maintain that it is best to raise these little patients 
in the mountains, or that they should be sent for frequent vacations 
to a high altitude. But I have seen excellent results in many cases 
which were sent to the seacoast, or to some forest climate. It is 
remarkable how quickly these children recuperate after a few weeks 
out in the open air, away from the city. 

Many of these children do not eat enough, and the emaciation 
resulting from the smouldering tuberculous process in the chest is 



710 TREATMENT OF VARIOUS FORMS OF TUBERCULOSIS 

increased by the lack of nourishment. The anorexia is very often 
relieved by open-air life. A child in the city may not eat enough or 
may have an actual abhorrence for food. But as soon as it is removed 
to the country, the desire for food is increased; often the appetite 
becomes ravishing a few days after arrival in the country. 

In those who cannot afford to go to the country the anorexia may be 
relieved by open-air life in the city. They should be urged to spend 
the greater part of the day outdoors, and sleep in rooms with open 
windows. In urgent cases there should be no schooling. The modern 
open-air schools are of questionable utility, especially during the 
winter when the bitter cold is apt to prove unbearable to both the 
teachers and the pupils. The child needs not only fresh air, but exer- 
cise is just as important. This keeps the child warm in the coldest 
day. I have very little confidence in the educational value of the open- 
air classes; so far as I have observed, there is hardly any study during 
cold days. A child run down to such an extent as to need open-air 
life throughout the day and night is unfit for schooling, and should be 
taken out to the country for a few months or a season, or taken out of 
school for a similar period, until it recuperates, when it may resume 
studies. 

The food of these children need not differ from that suitable for 
any child of the same age, but it should be plentiful, appetizing, and 
nourishing. It is even more difficult to place a child on a special diet 
than an adult. And there is no special need for such a procedure. It 
is, however, important to see to it that it does consume a sufficient 
quantity of proteids and fats. In children between two and four years 
of age, milk, cream, and eggs supply these requirements ideally. But 
older children should be urged to eat meats and poultry, and butter 
is the best source of fat for them. It is the most assimilable form of 
fat that can be given to the vast majority of children. Those who do 
not thrive on this diet, or who will not take a sufficient amount of 
butter, should be given cod-liver oil. The vast majority of children 
take it pure, or with malt. Most of the emulsions contain very little 
of the oil and are nauseous. 

Children with enlarged bronchial glands will almost invariably do 
well under this mode of treatment. It is often astonishing to watch 
the recuperation of an emaciated child within one or two months after 
being placed under this treatment. It is encouraging to watch the 
great improvement shown by most of the children taken from the 
tenements of New York City to the country or Preventorium. In 
some obstinate cases it is necessary to repeat the vacation twice 
annually for several years. Some should be kept out of town until they 
reach adolescence. But it should always be remembered that they all 
do well if properly treated ; the development of chronic phthisis before 
the age of ten is exceedingly rare, and infrequent before the age of 
fifteen. 

There is, however, one danger to which these children are exposed. 



PULMONARY TUBERCULOSIS IN CHILDREN 711 

The endemic diseases of childhood, measles, whooping-cough, scarlet 
fever, etc., produce anergy or lowered reactive powers (see p. 106) 
to tuberculosis. They are therefore to be guarded against these 
diseases. Many a child, doing well despite tracheobronchial adenitis, 
succumbs to bronchopneumonia complicating measles or whooping- 
cough. ^ It is very difficult to carry out prophylaxis against these 
endemic diseases in children living in the tenements of large cities; 
and in those who attend school in any part of a city, where there are 
so many "carriers." And we cannot isolate a child from intercourse 
with other children for obvious reasons. This is a fact which is often 
not considered in this connection by those eager to do something 
along these lines. If all efforts at prevention of complicating dis- 
eases have failed, and the child does develop one of them, the treat- 
ment should be very careful, and during convalescence the patient 
should be sent to the country for a month or more. 

But infants can be shielded against infection with measles, whooping- 
cough, etc., because they are always in the immediate care of the 
mother. Infants known to have been infected with tuberculosis should 
be kept away from the proximity of other children who are liable to 
be "carriers." It is just during infancy that measles and whooping- 
cough are likely to do most harm when attacking a subject harboring 
tuberculous infection. 

Medical treatment is not indicated in most cases, excepting where 
there is anemia, cough, etc. These symptoms are best relieved by the 
open-air treatment. But we may in many cases assist or accelerate 
the improvement by the administration of iron. The old syrupus ferri 
iodidi may be given in doses of 3 to 5 drops to children three years of 
age, and more in proportion to older children. Iron tropon is another 
good and palatable preparation for these anemic children. The hypo- 
phosphates do good in many cases. 

Children showing catarrhal symptoms, when not due to inflam- 
matory conditions of the nose and throat, do well with creosote in small 
doses. It may be given in doses of from i to J drop diluted in milk. 
Any of the derivatives of creosote may be given in powder or in syrup 
form. This will often relieve a cough much more effectively than 
sedative drugs. 

Specific treatment has been used with less success in children than 
in adults. It must be remembered that statistics of a number of 
children treated with any method, including tuberculin, are of no 
value if they show that of so many treated no deaths have occurred. 
Death due to pulmonary tuberculosis, excepting meningitis, in children 
over two and under fourteen years, is exceedingly rare. For these 
reasons, orphan asvlums show such splendid results— children ol 
tuberculous parentage do not develop phthisis while they are in the 
institutions. But in children tuberculin is not indicated because the 
psychic effect, which is the main curative factor in adults, is lacking. 
I can see no reason for giving tuberculin to children. 



712 TREATMENT OF VARIOUS FORMS OF TUBERCULOSIS 

Tuberculosis in the Aged.— Most aged phthisical patients are 
emaciated and debilitated. In many nourishment cannot be given 
in plentiful amount because they lack teeth for mastication, and most 
of them suffer from disturbances in the motility and secretions of 
the stomach and intestines. They also have arteriosclerosis, sclerotic 
kidneys, and do not bear the ingestion of large quantities of proteids. 
Fats are apt to induce diarrhea more often than in youthful subjects. 

These difficulties in the dietetics of aged consumptives may be 
overcome within limits by first ordering the repair of the teeth. Then 
they may have a diet consisting mainly of milk, cream, and cereals. 
Fish is also well assimilated by aged persons, and they should take it 
when, for any reason, meats are not tolerated. But so long as the 
condition of the kidneys is not such as to contra-indicate meats or 
poultry, they may be allowed in moderate quantities. Vegetables 
may be given so long as there is no diarrhea. While in younger phthis- 
ical patients alcohol is to be tabooed, it is different with aged patients. 
If they have been accustomed to alcohol it is not advisable to attempt 
instituting reforms at an advanced age. In some cases alcohol is even 
of distinct benefit, if not abused. 

Old patients do not bear outdoor life as well as younger ones. The 
same is true of high altitude. They must have warm rooms for living 
and sleeping. In fact, if they can afford it they should spend the 
winter in some southern region. The intense cold of the winter has 
a very deleterious effect on them because of the defective circulation — 
especially the peripheral — rigid arteries, sclerotic kidneys, pulmonary 
emphysema, etc., with which many are affected. But they need 
fresh air. While they should sleep in warm rooms, the windows must 
be kept open. 

Cardiac derangements are to be carefully treated by rest, digitalis, 
strophanthus, etc. Myocarditis is, however, not relieved by these 
remedies and, in addition to rest, small doses of nitroglycerin, fre- 
quently repeated, often have a beneficial influence. The iodides are 
very good in many cases, and should be given in moderate doses. In 
many patients the dyspnea is relieved by this remedy much more 
effectively and lastingly than by anything else. 

Fever is to be treated according to the principles discussed in 
Chapter XLI. Most senile patients have no fever, but at times 
we encounter some with pyrexia of longer or shorter duration. Those 
in whom the fever is mild and evanescent require rest in bed until the 
temperature comes down to normal. Very old persons, over sixty 
years of age, do not bear fever very well, and must be given anti- 
pyretic treatment. Pyramidon in 5- grain doses may be administered 
three or four times a day. 

The cough and expectoration need no treatment as long as they 
are not excessive. Otherwise, small doses of codein or heroin should 
be given. In many cases the expectoration is profuse and contains 
numerous tubercle bacilli. It may be greatly influenced by posture, 



TUBERCULOSIS DURING THE MENOPAUSE 713 

as in bronchiectasis, and postural treatment may be attempted. 
But this is difficult with old persons, because of their weakness and 
debility they cannot withstand the vigorous cough this mode of 
treatment is apt to induce. 

Tuberculosis during the Menopause. — Tuberculosis in women 
during the menopause is apt to be complicated by symptoms which 
are not seen in other phthisical patients. Considering the profound 
impression made by the tuberculous toxemia on the sexual sphere 
(see p. 259), there is no wonder that at the "critical period" tubercu- 
lous women should present special symptoms. 

Many are more or less obese despite the continued activity of the 
tuberculous process in the lung. Dyspnea is very frequent and many 
complain of cardiac palpitation. Hemoptysis is very frequent, and 
may replace the menstrual flow, though I should hesitate before 
considering it vicarious menstruation. Copious hemorrhages are 
uncommon; I am under the impression that they are less common 
than among others with similar lesions. But streaky sputum and 
small hemorrhages are very frequent. In addition there are most of 
the usual symptoms of the menopause — hot flushes; headaches, etc., 
and profuse perspiration. Combined with the symptoms of phthisis 
these symptoms of the menopause make this class of patients proper 
subjects for special treatment. 

In addition to the treatment of phthisis outlined above, the special 
symptoms need attention. I have had several cases in which repeated 
hemoptysis was stopped by the administration of the extract of the 
ovaries or the corpus luteum. Indeed, most of the annoying symptoms 
which torture the unfortunate woman more than those caused by the 
tuberculous process, may be relieved by the timely and proper admin- 
istration of these remedies. It is also a fact worthy of remembering 
that during the climacteric phthisical women do not bear the admin- 
istration of tuberculin very well; most are apt to be harmed by 
specific treatment. 

The cough and insomnia also are best relieved by the ovarian sub- 
stance; sedatives and hypnotics often aggravate this condition, 
though in many cases bromides and valerianates are effective. 



CHAPTER XLIV. 
TREATMENT OF COMPLICATIONS. 

Pleurisy. — Dry localized pleurisy occurring during the course of 
phthisis needs no special treatment, excepting to relieve the pain which 
is at times annoying. In mild cases external applications may suffice 
to give the patient comfort. Any of the belladonna plasters, or a sin- 
apism may do ; while some apply tincture of iodin. The writer finds, 
however, that the administration of salicylates often relieves these 
pleural pains much better than anything else. Aspirin, in doses of 
from 5 to 10 grains three or four times a day, may be given in cases in 
which sodium salicylate is liable to derange the stomach. 

In acute cases of pleurisy the pain may be very severe during the 
first few days before the effusion appears and may necessitate the 
administration of morphin, J to } grain hypodermically. In most 
cases it is not necessary to repeat it, but it is better to strap the chest 
with adhesive plaster. As soon as the effusion appears the acute pain 
usually ceases. 

The patient is to be kept in bed as long as the fever lasts. But 
during the later stages he may be permitted to take mild exercises. 
The diet is to be given in accordance with the temperature and the 
tuberculous process in the lungs. 

It is not advisable to make any efforts to hasten absorption of the 
fluid in cases of tuberculosis. The fluid may be serving a useful pur- 
pose by compressing the lung and facilitating the healing of the lesion 
in the same manner as an artificial pneumothorax does, and also 
because of some biochemical effects (see p. 450). On this prin- 
ciple effusions may be permitted to remain for months. But in 
case the effusion causes severe dyspnea, cyanosis, cardiac weakness, 
insomnia and other urgent symptoms, it should be aspirated at least 
partially. But even then aspiration should be left as a last resort 
because speedy withdrawal of the fluid and rapid expansion of the 
lung may awaken the tuberculous process into acute activity. The 
writer has observed this to happen in several cases. 

It is best to first try autoserotherapy. Five to 10 c.c. of the fluid are 
withdrawn with an aspirating syringe and reinjected into the subcuta- 
neous tissue. A good way is not to remove the needle after the syringe 
is filled with the fluid, but while withdrawing it, when its point reaches 
the subcutaneous tissue, to turn it parallel to the surface of the chest 
and to inject the fluid right then and there, as was described by the 
writer 1 elsewhere. This can be done several times on alternate days. 

1 Jour. Am. Med. Assn., 1913, lx, 962. 



SPONTANEOUS PNEUMOTHORAX 71 r> 

In most cases there will be noted an increase in diuresis, and the level 
of the fluid begins to sink, so that within a couple of weeks it may be 
absorbed altogether. 

In cases in which autoserotherapy is of no avail, and the general con- 
dition of the patient demands removal of the effusion, aspiration should 
be done. It is advisable not to remove all the fluid at one sitting, but 
to do it on alternate days, each time withdrawing a part. In many 
cases the pleura refills soon after tapping, and it is necessary to assist 
the absorption by giving a salt-free diet, and to reduce the amount 
of fluid ingested by the patient. Diuretin may be of assistance by 
increasing diuresis. But other drugs, reputed as assisting absorp- 
tion of pleural effusions, as the iodides, are impotent in this regard. 
Emptying the bowels daily with salines, if there are no eontra-ihdica- 
tions, may assist in the absorption of the fluid. 

Empyema. — The treatment of purulent effusion during the course 
of phthisis is very unsatisfactory. Some authors have stated that 
when the pus shows streptococci and staphylococci, the prognosis is 
better, and resection of one or two ribs may bring about a cure, while 
in cases in which the pus shows the presence of tubercle bacilli, opera- 
tion is futile. In the experience of the writer there has been observed 
no difference from this viewpoint. On very rare occasions we meet 
with a case in which several aspirations of the pus cure the empyema. 
Similarly the writer has had cases of localized and encapsulated 
empyemata which broke through bronchi, the pus was expectorated 
and the patients recovered. In the vast majority of cases we keep 
on withdrawing larger or smaller quantities of pus, but the chest fills 
up again in a short time. In some cases fistulse form along the track 
of the needle, discharging pus externally. 

The results of operations for empyema complicating phthisis are 
unsatisfactory. A simple incision for the evacuation of the pus is 
nearly always followed by a fistula necessitating the patient to go 
around with a foul-smelling bandage for the rest of his life. For this 
reason most physicians are at present satisfied with the aspiration 
of the pus, repeated according to indications. 

^Whether treated by operation or thoracocentesis, the fever usually 
keeps up, dropping after the removal of part of the pus, but rising 
again within a few days. Emaciation, nightsweats, anorexia, diarrhea, 
etc., keep on; amyloid degeneration of the viscera, notably the liver, 
spleen, kidneys, and intestines, develops and the patient sooner or 
later succumbs to exhaustion. 

The suggestion of some authors that after removing the pus nitro- 
gen should be inflated into the pleura has been tried by the writer, 
not found to offer any advantages, and abandoned. 

Spontaneous Pneumothorax— In the treatment of this complication 
we must consider whether this accident may not ultimately turn 
out of use by collapsing the lung and thus facilitating the healing 
process as the artificial variety often does. This is exceedingly rare; 



716 TREATMENT OF COMPLICATIONS 

still now and then we meet with a case in which a spontaneous pneu- 
mothorax is followed by improvement in the symptoms of the original 
disease. 

The acute onset with shock, pain, dyspnea, etc., demands active 
treatment. The indications are- clear: The patient is to be relieved 
of the urgent and menacing symptoms, his heart is to be stimulated, 
etc., which is best done by a hypodermic injection of morphin. But 
if the patient is not calmed, and the dyspnea is urgent, thoracocentesis 
is to be performed. This is often the only means at our command to 
relieve the extreme and agonizing dyspnea. Tapping the air in the 
affected pleural cavity gives prompt relief, though unfortunately only 
of short duration in most cases. Plunging a hypodermic needle into 
the affected side is sufficient, because the expiratory pressure within 
the pleura is greater than that of the external atmosphere. It is good 
to attach a rubber tube to the needle by one end, wliile the other is 
placed in a pail of water, thus forming a water valve which permits 
the free exit of the air from the chest, but prevents its return . 

If the relief thus obtained is only transitory, the operation is 
repeated; in some cases it may be necessary to repeat the tapping 
four, five, or even seven times during the first day. Some have tried 
to obviate this by inserting a cannula and leaving it in the chest 
wall for several hours or days; the rubber tube all the time in the 
water. But I have found it very difficult to retain the needle in 
place and to keep it aseptic. For this reason I prefer to make several 
punctures as the urgency of the symptoms demands. 

Many theoretical objections have been raised against tapping the 
chest in these cases. But one has only to witness a case in which the 
agonizing pain and air hunger are promptly relieved by tapping, to 
appreciate that this is the only measure which gives relief. As in 
urgent cases of any kind, theoretical considerations are left until the 
menacing symptoms are under control. In fact, after one tapping the 
patient begs for another when the dyspnea returns. 

I have recently been more successful with induction of counter- 
pressure within the pleura by injection of air in the way we do when 
inducing a therapeutic pneumothorax. This was first suggested by 
Morelli. It appears from actual measurements that in the vast 
majority of these cases the intrapleural pressure is negative, even 
though the patient suffers from severe dyspnea. Increasing the amount 
of air in the pleura the perforation is closed by the air pressure, the 
edges are held together and they soon heal. Closure of the fistula 
prevents further entry of septic matter from the lung into the pleura. 
As done by A. Pisani, 1 a needle connected with a manometer is intro- 
duced into the pleura and, if the pressure is found positive, some of 
the air is withdrawn. Then the tube leading from the needle is con- 
nected with the usual pneumothorax apparatus and air is allowed to 

1 Gazzetta degli Ospedali e delle Cliniche, 1917, xxxvii, 379. 



HYDROPNEUMOTHORAX 7 1 7 

enter the pleural cavity until the manometer registers 5, 10, or even 
20 cm. positive water pressure. 

In several cases in which this method was tried by the writer, relict' 
was noted immediately in two out of three. In some cases we may 
continue the pneumothorax treatment, just as we do in cases of thera- 
peutic pneumothorax. 

We meet with cases in which the embarrassment of the circulation 
and respiration continues in spite of repeated tappings, or introduction 
of air, and the prognosis is gloomy. The causes are not primarily 
mechanical, but physiological. The opposite lung is congested and 
the circulation is thereby more embarrassed than by the displacement 
of the mediastinum. In these cases we may try oxygen inhalation, 
and cupping all over the posterior aspect of the chest. Some use wet 
cups or venesection to relieve the right ventricle which is becoming 
paralyzed from extreme overdistention. "I have no doubt," says 
West, " that life might be sometimes saved by timely venesection and 
it is certain that bleeding is not so much employed in these urgent 
cases as it ought to be." 

The heart action is to be sustained by large doses of strychnia, 
digitalis, spartein, or camphor. 

In milder cases, especially those in which the pneumothorax is only 
partial and the symptoms are not so urgent, the treatment is less 
vigorous. The dyspnea, pain, and distress are usually controlled by 
a dose of morphin hypodermically, and within a day or two the 
patient feels quite comfortable. 

The after-treatment, if the patient survives three or four days, is 
that of the underlying tuberculous process in the lungs. Inasmuch 
as the pneumothorax with its sudden onset and agonizing symptoms 
often leaves the patient in a debilitated condition, rest and proper 
feeding are to be enforced. In rare cases the pneumothorax, acute 
and menacing as it was at the onset, turns out to be "providential," 
as some French authors say. The collapsed lung is given an oppor- 
tunity to heal and recovery may take place ultimately. Some 
recommend that in such cases the pneumothorax should be continued 
by injections of nitrogen in the approved manner. 

* After the menacing symptoms have abated, the patient, regaining 
his strength and composure, provided he has no fever, may be per- 
mitted to leave his bed and take mild walking exercises. We know 
now from experience with artificial pneumothorax that one can do 
considerable exercise or even work when one pleural cavity is filled 
with air and the lung collapsed. But a spontaneous pneumothorax 
is not alwavs closed and exercises may cause some of the morbid 
secretions to enter the pleura through the fistula and cause pyothorax 
Hydropneumothorax.— The treatment of effusion into a pleural 
cavity filled with air is conservative, just as that of pneumothorax. 
The fluid is absorbed sooner or later spontaneously X\e now nave 
experience with this condition in cases with artificial pneumothorax. 



718 TREATMENT OF COMPLICATIONS 

So long as there is no fever or dyspnea, the patient may be allowed 
considerable exercise. But in case the intrathoracic pressure becomes 
high and produces dyspnea when the patient is at rest, the pressure 
must be reduced. This can be done by withdrawing some of the air 
or fluid. The latter is the best. With an aspirating apparatus a 
part of the exudate is withdrawn.' In many cases the operation has 
to be repeated. In favorable cases this withdrawal stimulates the 
absorption of the rest of the fluid. In several cases I have had good 
results with autosero therapy (p. 714). 

Pyopneumothorax. — The treatment of this complication is very 
unsatisfactory. Operative interference has not given encouraging 
results. At best, a fistula is left in the chest which discharges pus 
indefinitely. The ultimate result is worse than when only tapping of 
the pus is resorted to. The indications, therefore, are to aspirate the 
pus at frequent intervals with a view of keeping the patient afebrile 
as far as possible. The bacteriological findings have no influence on 
the prognosis and treatment, as has already been stated when speaking 
of empyema complicating phthisis. 

Laryngeal Tuberculosis. — Many cases of tuberculous laryngitis 
show a strong tendency to spontaneous cure, especially in patients 
whose lung lesion also manifests a tendency to improvement. In fact, 
the progress of the lesion in the larynx goes hand-in-hand with the 
progress of the lung lesion, though the physical signs of the latter are 
apt to be obscured by the former. This is clearly seen in cases in which 
the induction of a therapeutic pneumothorax is effective in curing the 
patient. If there has been a laryngeal lesion it often shares in the 
general improvement of the patient. 

In my experience, local treatment is not often effective in enhancing 
cicatrization of laryngeal lesions. When carried out vigorously, it is 
apt to do harm. The application of local escharotics and cauteriza- 
tion has been harmful in the long run or of no benefit in the vast 
majority of my cases. As has been pointed out by St. Clair Thomson, 1 
lactic acid, which is the favorite drug used by laryngologists, is 
unavailing except in strengths of 50 per cent, or more. Hence, sprays 
of 2 per cent, are nothing but irritating. Frequent applications are 
also irrational, the object being to produce an eschar which does not 
separate for one to three weeks. When the slough is detached a 
healing ulcer is exposed; but there are generally deeper deposits 
requiring a repetition of the cauterizing process, so that four to twelve 
applications may have to be spread over as many months. The use 
of a 20 to 25 per cent, solution of argyrol, or a 2 per cent, solution of 
methylene blue for local application, as advised by Fetterolf, is less 
likely to be painful or harmful. Where the mucous membrane is 
unbroken no local application of drugs does any good. 

In a few cases I have seen excellent results when the patient ceased 

i Diseases of the Nose and Throat, New York, 1912, p. 606. 



LARYNGEAL TUBERCULOSIS 719 

talking altogether, thus affording perfect rest to the larynx. But it 
must be done thoroughly. The patient should have a pad and pencil 
and carry on all conversation in writing. In two cases, both women, 
in whom this treatment was carried out perfectly, the laryngeal lesion 
healed. There are, however, few patients who want to submit to tin- 
treatment for a long time. In patients with advanced and active lesions 
in the lungs, there is no reason for trying it, because they are doomed 
anyway. 

As has been shown by Fetterolf, 1 there is one form of the disease 
in which unlimited use of the voice is advisable, this being the variety 
in which the vocal cords are the only parts of the larynx involved. 
This is commonly called the "chorditic" form, the cords appearing 
slightly congested and having on their upper and to a slight extent 
on their mesial aspect a number of reddish granular growths. These 
are possibly sometimes submucous tubercles, but more frequently 
are distended mucous glands with their duct orifices occluded. Vocal 
exercise aids in clearing up the condition, and it is in this form that 
improvement of the voice so frequently follows an acute coryza. 

In all cases with dysphagia palliative treatment must be applied. 
We may try to obtain relief by laryngeal insufflations- of 3 to 5 grains 
of orthoform or anesthesin. It is only effective when there is ulceration 
and the powder remains on the ulcer. If given about one hour before 
the main meal the patient may be comfortable for a whole day. The 
following formulae may also be used : 

3— Orthoformi gr. xxx 2.0 

Iodof ormi gr. xxx 2.0 

Mentholi gr. vj 0.4 

M. S. — Insufflate a few grains one hour before meals. 

3 — Cocaine hydrochloridi gr. x 0.7 

Morphinae hydrochloridi gr. ij 0.1 

Mentholis g r - xv 1 -° 

Iodoformi 5ij 8.0 

Acidi borici 3ij 80 

M. S. — Insufflate a few grains one hour before meals. 

The application of these powders is to be made with special insuffla- 
tors. They are designed so that the spray goes vertically downward, 
not backward into the pharynx. 

In some cases the dysphagia is severe and not at all influenced by 
the application of remedies locally. Injections of alcohol into the 
superior larvngeal nerve may then be tried. Relief from pain may be 
obtained lasting several weeks. Rudolf Hoffmann was the first to 
suggest this mode of treatment. The technic of the injection is thus 
given bv J. Dundas Grant: 2 

Place the patient in a horizontal position and, with the thumb ot 
the left hand, press the sound side of the larynx toward the middle 

1 Hare's Modern Treatment, Philadelphia, 1911, ii, 402. 
? Lancet, 1910, i, 1754. 



720 



TREATMENT OF COMPLICATIONS 



line so that the affected half projects distinctly; the other fingers of 
the hand lie on this. The index finger enters the space between the 
thyroid cartilage and the hyoid bone from without until the patient 



flyoid bo7ie 




Thyrohyoid muscle - 
Lary?zyeal artery -- 
Omohyoid muscle 
Sternohyoid muscle—- 
Carotid artery ■--' 



Fig. 99.— The thyrohyoid region. (Grivot.) 




flyoid bone--" 
Thyroid cartilayi 




Cricoid cartilage 



Fig. 100. — Space where to insert the needle for producing anesthesia of the superior 
laryngeal nerve. (Celles.) 



LARYNGEAL TUBERCULOSIS 72] 

announces that a painful spot had been reached. With a little 
practice one arrives at it at the first go-off, when one has become 
familiar with the topographical relations. Now the nail of the index 
finger is placed on the skin (which has been previously disinfected) 
in such a way that the point of entrance for the needle lies opposite 
its middle. The needle is pushed in for about 1.5 cm. and this distance 
is marked off on the needle perpendicular to the surface of the body. 
According to the thickness of the subcutaneous layer of fat, the 
perforation has to be more or less deep. The needle is then carefully 
moved so as to seek a spot at which the patient states that he feels 
pain in the ear. The syringe filled with 85 per cent, alcohol warmed to 
the temperature of 45° C. (113° F.) is screwed on to the handle and 
the piston is then slowly pressed down. The patient now feels pain 
in the ear, the passing off of which he indicates by raising his hand. 
During the operation he has to avoid both swallowing and speaking; 
if, however, he makes a movement of swallowing we must follow the 
movement of the syringe with a light touch. The injection is kept up 
urtil no further pain occurs in the ear; then the needle is removed and 
collodion or sticking plaster is placed on the spot of the injection 
without pressure. The needle employed should be one with a point 
bevelled off much more obtusely than in an ordinary hypodermic 
needle, so as to avoid the risk of puncturing a vessel. 

I have tried this method in many cases and obtained relief for the 
patient in about 50 per cent. Failures are due to missing the nerve, 
which is unavoidable in many cases. 

There are cases in which all the above fail to relieve the sufferer 
and all we can do is to give large doses of anodyne drugs. In some we 
may obtain relief by helping the patient in the following manner while 
he eats: A trained person stands behind the patient and makes firm 
and even pressure at the angle of each jaw at the moment of swallow- 
ing. Another way is known as Wolfenden's position: The patient 
lies prone over the bed with the face over the end and sucks the 
nourishment through a glass tube from a cup on the floor. These 
maneuvres seem cumbersome, to say the least, but when having 
under our care a patient who cannot swallow even water without 
severe pains in the throat, we are ready to try anything. 

There remains yet to mention the various operations of curettage 
and cautery which laryngologists perform in these cases. Some 
employ direct laryngoscopy while operating, but this is not only vio- 
lent, but the results have been disastrous in all the cases that have 
been done for me. In advising operation to a patient of this class we 
must first ascertain the general and the local condition of the lungs. 
In case the prognosis is poor because of the general condition, there is no 
reason for operating. I always object to operations in febrile and 
cachectic patients. 



46 



INDEX OF AUTHORS. 



Adami, 58, 142 

von Adelung, 671, 694 

Albrecht, 89 

Aldrich, 508 

Alexander, 46 

Allard, 451, 455, 456 

Amenomiya, 500 

Ameuille, 448 

Ancell, 57, 223 

Anders, 103, 201, 207, 209 

Anderson, John F., 53, 245 

Andral, 207, 299 

Antylus, 628 

Aretaeus, 208, 265, 614 

Arkin, 628 

Arloing, 38 

Arluck, 393 

Arneth, 244 

Arnsperger, 321 

Aschoff, 142 

Ash, 471 

Atwater, 615 

Auche, 90 

Aude, 252 

Aufrecht, 49, 122, 274 

Ayer, 148 

Bach, 459 

Bacmeister, 46, 48, 95, 98, 117, 347 

Baer, 700 

Balboni, 676, 677, 678 

Baldwin, 33, 40, 92, 126, 544, 636 

Ballenger, 495 

Bamberger, 248 

Bandelier, 300, 347, 385, 639 

Bang, 97, 126, 652, 654 

Barbier, 247, 274 

Bard, 375, 385, 461 

Bardswell, 184, 611, 619 

Barjon, 436 

Barnes, 261, 627 

Barot, 407 

Barr, 451 

Bartel, 43, 46 

Bartlett, 52, 53, 58 

Bartlett, J. R., 123 

Barwell, 494, 497 

Bar wise, 111 

Bauer, 112 

Baumgarten, 88, 49, 54, 88, 89, 127, 135 

Bayle, 325, 375, 450, 499 

Beale, 191 



Beck, 346 

Beddoe, 263 

Behrend, 343 

Behring, 42, 117, 129, 389 

Beitzke, 38, 48, 50, 142 

Bell, 82 

Benda, 505 

Benedict, 576 

Bennet, 223 

Bergel, 592 

Bergheim, 93 

Bernard, 462, 697 

Bernheim, 539 

Bertillon, 73 

Besredka, 347, 623 

Besseson, 266 

Bezangon, 237, 274, 299, 352, 385 

Biach, 460 

Bibb, 315, 320 

Biermer, 360 

Biggs, 72, 569 

Binet, 93 

Birch-Hirschfeld, 48, 64, 90, 98, 103 

Bisaillon, 70 1 

Bittorf, 458 

Blake, 403 

Blakiston, 452 

Blomel, 639 

Blum, 249 

Blumberg, 460 

Boardman, 175, 315, 320 

Bodington, 574, 599 

Bohland, 241 

Bonney, 274, 500, 659 

Borschke, 501 

Boston, 340, 385 

Bowditch, 451 

Bowlby, 412 

Bramwell, 452 

Brandenburg, 494 

Brauer, 667, 668, 672 

Braun, 415, 418 

Bray, 182, 183, 188, 308 

Brehm, 245 

Brehmer, 92, 198, 566, 574, 594 

Briger, Brieger, 225 

Broders, 526 

Bronfenbrenner, 348, 450 

Brooks, Harlow, 92, 108, 126, 539 

Brown, L., 21, 103, 265, 274, 331, 323, 

532, 572, 589, 602, 610, 641 
Brown, William Garet, 545 



724 



INDEX OF AUTHORS 



Brov?n-Sequard, 215 
Bruce, 376, 513 
Bruckner, 343 
Brugelmann, 101 
Brunon, 122 
Brunton, Lauder, 600 
Budd, 223 

Bullock, 500, 688, 694 
Bulstrode, 106 
Burkhardt, 58, 60, 63, 68 
Bums, 21, 103, 104, 209, 231 
Bushnell, 105, 117, 158, 299, 305, 309, 
310 

Cabot, 209, 212, 310 

Calmette, 50, 51, 65, 67, 94, 117, 125, 

344, 347, 389 
Capps, 255, 423, 424 
Carpi, 693 
Carr, 400 

Carrington, 558, 575, 579 
Carson, 666 
Castaigne, 461 
Castellani, 486 
Cattermole, 65, 70 
CavagDis, 89 
Celles, 720 
Chalier, 91 
Chalmers, 487 
Chamberland, 90 
Chambers, 57 

Chantemesse, 421, 449, 506 
Chapin, 42, 43, 55 
Chapman, 184, 611, 604, 619 
Charvot, 510 
Chausse, 42 
Chauvet, 336 
Cheyne, 504 
Chiari, 490 
Childs, 321 
Chittenden, 614 

Clark, Andrew, 211, 328, 375, 377, 552 
Clark, James, 223, 260 
Claypole, 486 
Clemenger, 178 
Clough, 246 
Clouston, 255 
Cobbett, 30, 38, 51, 54, 63, 85, 108, 131, 

563 
Cochrane, 642 

Cohen, Solis M., 233, 245, 252, 491 
Cohn, 319, 320 
Colley, 677 
Collis, 110, 111 
Combe, 255, 390, 614 
Condie, 201 
Coonley, 540 
Coriveaud, 452 

Cornet, 21, 35, 95, 110, 198, 385 
Corper, 85, 628 
Cotton, 20, 43, 51 
Councilman, 53 
Courcoux, 421, 429 
Courmont, 697 



Couston, 451 
Cowan, 467 
Cowie, 91 
Craig, 244 
Crofton, 93 
Cruice, 499, 510 
Cullen, 260 
Cummer, 459 
Cummings, 575, 578, 579 
Cummins, 68 
Cursham, 506 
Czerny, 398 

Da Costa, J. M., 283 

Da Costa, John Chalmers, 405 

Damman, 39 

Daremberg, 185, 187, 610, 618 

Dastre, 657 

Davis, 27 

Day, 28 

Debains, 347, 523 

Debove, 609 

Dehn, 321 

Delafield, 146 

Delepine, 31 

Delhern, 158, 471 

Dellile, Armade, 408, 539 

Delpeuch, 263 

Demme, 540 

Demoiseau, 431 

De Renzi, 627 

Destree, 252 

Dettweiler, 187, 612, 645 

Deulafoy, 212 

Dioscorides, 628 

Doane, 20 

Dobell, 223 

Dobrovici, 534 

Doerr, 27 

Dold, 245 

Donaldson, 434 

Dorset, 19 

DowdeU, 506 

Doyen, 314 

Drasche, 460 

Duboff, 559 

Dubrull, 451 

Duckworth, 524 

Dunham, 315, 319, 433 

Dworetzky, 494, 495, 496, 497 

Eastwood, 64 

Eden, 53 

Ehrlich, 448, 522 

Einhorn, 225 

Elderton, 124 

Ellis, 431 

Emerson, 461, 462 

Engel, 255 

d'Espine, 407 

Estor, 112 

Etienne, 506 

Ewart, William, 147, 274, 309, 363, 406 



INDEX OF AUTHORS 



72.") 



Fagge, 103 

Faginoli, 688 

Faisans, 241 

Fenwick, 223 

Fenwick, W. Soltau, 168, 223, 255, 

Fernet, 449 

Fetterolf, 282, 305, 559 

Fieldes, 348 

Finkler, 476 

Fisac, 110 

Fischer, 246 

Fischera, 487 

Fisher, 611, 614 

Fleiner, 420 

Fleischner, 540 

Flexner, 486 

Flick, 657 

Fliessinger, 592 

Flint, 220, 283, 359, 512 

Floresco, 657 

Florschutz, 124 

Floyd, 422, 676, 686 

Flligge, 41, 42, 44, 576 

Fochi, 656 

Folin, 614 

Fordvce, 131 

Forlanini, 693, 694 

Fontana-Tribeudeau, 487 

Forster, 364 

Forsyth, 632 

Fowler, 84, 142, 636 

Fox, Wilson, 164, 201, 220 

Francois-Frank, 215 

Frankel, Albert, 246, 643, 327 

Franz, 346 

Fraser, 37, 587 

Freudenthal, Wolf, 497, 577 

Freund, 95, 96, 98, 117 

Frev, 657 

Friedmann, F. F., 26, 88, 89, 534 

Friedreich, 359 

Fulton, 83 

Funk, 201, 223, 226, 287 

Fussell, 459 

Gabb, 459 

Gabbet, 173 

Gaffky, 52 

Galen, 220, 221, 265, 628, 645 

Ganghofner, 343 

Garb, 110 

Garland, 431 

Garnier, 540 

Gartner, 89 

Garvin, 476 

Gassmann, 226 

Gaube, 93 

Gaujot, 510 

Geddes, 95 

Geisbock, 242 

Gerhardt, 217, 326, 657 

German, 426 

Ghon, 52, 140, 152, 359, 390 

Gibson, 408 



Gignaux, 211 

Gilbert, 85, 244, 364, 592, 674 
Gilliland, 315, 320 
Gimbert, 261 
501 Giraux, 112 
Glaister, 73 
Glover, 348, 385 
Goethe, 219 

Goldscheider, 274, 290, 291, 296 
Goodale, 100 
Gordon, 44 
Goring, 124 
da Gradi, 695 
Graetz, 176 
Graham, 462 

Grancher, 223, 274, 297, 406, 632 
Grant, 719 
Grasser, 112 
Graves, 373 
Grawitz, 243, 420 
Gray, 506, 508, 644 
Gregg, 85 
Griesinger, 104 
Griffith, 29, 37, 59, 63 
Grivot, 720 
Grober, 420 
Grocco, 433, 689 
Grvsez, 51, 65 
Guarini, 102 
Gueneau de Mussy, 222 
Guieysse-Pelliosier, 136 
Guinon, 394 
Guyenet, 500 



Hahx, 112 

Haldane, 111, 576 

Hall, D. C. 581 

Hall, F. de'Haviland, 211 

Halter, 110 

Halverson, 93 

Hamburger, 33, 52, 59, 65, 117, 394 

Hamman, 346, 451, 459, 476 

Hansemann, 116, 325, 638 

Harbitz, 46, 58, 59 

Harras, 95, 96 

Harrington, 252, 467 

Harris, 191 
: Hart, 95, 96, 98, 117 
| Hartley, 500, 506 

Harvey, 36 

Haupt, 124 

Haushalter, 506 

Haven, 244, 592, 674 

Hawes, 112, 309, 494 

Hayem, 225 

Head, 254 

Heberden, 236 

Hedges, 451 

Hefflebower, 522 

Heim, 198, 346 

Heise, 21, 323 

Hellin, 463 

Helmers, 627 

Hempelmann, 393, 395 



726 



INDEX OF AUTHORS 



Henderson, 509 

Henke, 154 

Hermann, 173 

Herter, 614 

Hess, 53, 540, 658 

Heublein, 410 

Heymann, 44 

Hierokles, 506 

Hill, Leonard, 576 

Hillenberg, 67 

Hiller, 245 

Hinsdale, 591, 596 

Hippocrates, 36, 234, 260, 263, 265 

Hirsch, 69 

Hirsch, I. S., 410 

Hirtz, 240, 527 

His, 99, 275 

Hodgkin, 190 

Hoffman, F. L., 110 

Hoffmann, F. A., 79, 101, 108 

Hoffmann, Rudolph, 719 

Holeman, 95 

Hoist, 317 

Holt, 392, 394 

Honeij, 407 

Honl, 91 

Honsele, 112 

Hoppe-Seyler, 418 

Horetsky, 112 

Howell, 407 

Hrdlicka, 67 

Huber, 258 

Humphrey, 508 

Hunter, 506 

Hutchinson, 225 

Hutchinson, Woods, 67, 127, 265 

Inman, 569, 571 
Iscovesco, 632 
Iwai, 95 

Jaccound, 632 
Jackh, 89 
Jackson, 486 
Jacob, 67 
Jacobi, 554, 622 
Jacobson, 258 
Jacoby, 177 
Jakowski, 449 
v. Jaksch, 179 
James, 592, 647 
Jam, 89 
Janowski, 224 
Jeannil, 112 
Jeannin, 223 
Jessen, 254 
Jex-Blake, 209 
Jones, 46 
Joseph, 177 
Jupille, 523 

Kagan, 245 
Keith, 99 
Kellogg, 613, 614 



Kendal, 28 

Kennerknecht, 245 

Kernig, 504 

Kessel, 246, 347 

Kidd, Percy, 103, 494, 499 

Kienboch, 467 

Kindberg, 158, 248, 450, 471 

King, 126, 309, 310, 532, 563, 611 

Kitasato, 35, 53 

Kjer-Petersen, 244 

Klebs, 32 

Klemperer, 54, 127, 225, 245, 246, 688 

Klenke, 22 

Klimmer, 637 

Knight, 594 

Knipfelmacher, 292 

Knott, 65 

Koch, 392 

Koch, Robert, 17, 23, 31, 33, 45, 82, 89, 

130, 324, 604, 637 
Kohler, 262 
Kohlisch, 42 
Konig, 112 
Koniger, 450, 453 
Koplik, 419 
Koslow, 245 
Koster, 451, 452, 455 
Krause, 262, 319, 322 
Krause, Allen K., 46, 86, 117, 559, 690 
Kreuscher, 694 
Kreuzfuchs, 317 
Kronig, 274, 285, 474 
Krumwiede, 25, 29, 39 
Kuban, 109 
Kulbs, 112 
Kurashige, 245 
Kiiss, 140, 349, 622 
Kuthy, 26, 92, 169, 199, 202, 224 

Laennec, 57, 134, 234, 361, 362, 450 

Landouzy, 263, 449 

Lange, 499 

Langstroth, 254 

Lartigau, 100 

Laschtschenko, 44 

Latham, 554, 600 

Lauritz, 226 

Learning, 305 

Lebert, 220, 499 

Lee, 576 

Lees, 274, 336 

Lehmann, 90 

Lemgey, 112 

Lemke, 694 

Lemoine, 524 

Leredde, 348 

Lesague, 508 

T .pcrjp 'nlo 

Letulle, 65, 144, 145, 149, 258, 260, 459 

Leube, 604 

Leudet, 364 

Levanditi, 131 

Levene, 32 

Levison, 223 



INDEX OF AUTHORS 



727 



Levy, 124, 129, 242 

Leyden, 565 

Libman, Emanuel, 216 

Lichtheim, 215 

Liebermeister, 245, 246, 506 

Limbeck, 243 

Lindhagen, 77 

Locke, 238 

Loeffler, 175 

Lombard, 57 

Lombardi, 265 

Lombroso, 95 

Londe, 91 

Longa, 449 

Longet, 215 

Loomis, 63, 328 

Lord, 219, 220 

Louis, 102, 164, 199, 201, 226, 460, 499, 506 

Lubarsch, 48, 53, 58, 60 

Luschka, 224 

Lyon, 684 

McCarthy, 220 

McCrae, 58, 143 

Mcintosh, 347 

McLean, 569 

McNeil, 129 

McSweeney, 600, 606 

Macht, 188, 189, 214, 656 

Mackenzie, Hector, 638 

Mackenzie, James, 254, 255 

Mackenzie, Morell, 494 

MacWhinnie, 580, 581 

Maffucci, 21, 23, 89 

Magnus-Alsleben, 205 

Mallory, 53 

Mandl, 665 

Mannheimer, 658 

Manning, 65 

Manoukhine, 347, 523 

Mantoux, 65, 196, 197 

Manwaring, 450 

Maragliano, 35 

Marcellus Empiricus, 628 

Marfan, 126, 226, 540 

Marie, 592 

Marmoreck, 247 

Marquard, 262 

Martius, 129 

Martley, 178 

Massol, 347 

Mathieu, 534 

Matson, 701 

Mayer, 524 

Mayo, 512 

Meader, 18 

Means, 683 

Melchoir, 226 

Meltzer, 683 

Mendel, 614 

Metchnikoff, 45, 67, 117, 135, 136, 550 : 

614, 616 
Mettetal, 34, 346 
Metzger, 522 



Mover, A., 467, 686 

Meyer, K. F., 540 

Meyer, N., 177 

Milchner, 89 

Miller, 476, 648 

Miller, H. R., 348, 523 

Miller, J. A., 245 

Mills, 247, 82, 509 

Mitchell, 30 

Mitchell, Philip,. 129 

Mitchell, Weir, 667 

Mohler, 20, 93, 220, 223, 226 

Moller, 26, 28, 92, 164 

Mongour, 506 

Monkenberg, 64 

Montgomery, 260 

Montgomery, C. M., 104, 105, 249 

Monti, 394 

Moore, 71 

Moreland, 189, 639 

Morelli, 716 

Morgan, 672, 686 

Moritz, 109, 672 

Moro, 67, 343 

Morris, 433 

Morton, Richard, 166, 228 

Mosenthal, 509 

Most, 95 

Mowat, 318 

Much, 18, 27, 38, 131 

Miiller, Berthold, 208 

Miiller, Fr., 501 

Munstermann, 501 

von Muralt, 153, 262, 592, 671 

Murphy, John B., 667, 677, 679, 694 

Musemeier. 39 

Musser, 271, 274, 360 

de Mussy, 242, 409, 424 

Naegeli, 58, 60, 63 

Nattan-Larrier, 144, 145, 149 

Neisser, 42 

Netter, 449 

Newman, 214 

Newsholme, 77, 106, 603 

Nichols, 110 

Nikolski, 458 

Niles, 266 

Nocard, 23 

Nolf, 487 

Norris, 103, 282, 300 

Nothnagel, 202 

Nowack, 90 

Oestreich, 283, 287 

O'Farrell, 487 

Ogle, 79 . 

Oliver, 110 

Opie, 61, 63, 458 

Orth, 38, 115, 130, 154, 490 

Osier, 451, 600 

Otis, 158 

Ottenberg, 216 

Overland, 67 



728 



INDEX OF AUTHORS 



Packard, 43 

Paillard, 164, 168 

Pappenheim, 245 

Parfit, 519 

Park, William H., 18, 20, 23, 25, 29, 37 

Parr, 260 

Parrott, 140 

Paterson, 230, 566, 569, 611 

Paterson, Robert C, 422, 437, 449 

Pawlow, 616 

Pearce, 53 

Pearson, Karl, 57, 81, 88, 124 

Pehu, 91 

Pensunti, 449 

Penzholdt, 188, 554, 645 

Peretz, 309 

Peron, 511 

Peter, Michel, 166, 168 

Peters, L. S., 500 

Peters, W. H., 261 

Petersen, 629, 490 

Petri, 27 

Petroff, 19, 21 

Petruschky, 35, 124, 346 

Phelps, 577 

Philip, 223 

Philip, R. X., 288 

Philippi, 639 

Pidonx, 164 

Pierce, 452 

Pierv, 92, 126, 200, 234, 263, 274, 300, 

"372, 385 
Pietrzikowski, 112 
von Pirquet, 66, 67, 511 
Plesch, 280 
Politzer, 145 
PoUak, 65, 223, 524 
Pomerov, 254 
Pope, 124, 365, 602 
Porter, 89 

Porter, William, 652 
Potain, 248 

Pottenger, 99, 222, 266, 150 
Poujade, 568 

Powell, 102, 242, 431, 460 
Preisich, 346 
Price, 212 
Prudden, 146, 148 

QlTERNER, 146 

Queryat, 449 

Rabinowitsch, Lydia, 27, 64, 130, 637 

Rabinowitsch, Marcus, 38 

Radcliffe, 348 

Radziejewski, 343 

Ramazzini, 108 

Ramond, 430 

Ranke, 402 

Ransome, 79, 81, 106 

Rasmussen, 149, 202 

Ravenel, 48, 50, 53, 100, 246 

Raw, 105, 524 

Raynaud, 524 



Reed, 245 

Reibmevr, 260 

Reiche, 202 

Reichenbach, 623 

Reinecke, 82 

Reinhardt, 59, 63 

Remhardt, Goodwin, 221 

Renon, 533, 622 

Reuben, 392, 395 

Reuschel, 343 

Revault, 506 

Ribbert, 48, 49, 117, 136 

Richet, 613 

Riddell, 467 

Riesman, 459, 476 

Ringer, 245, 657 

Risel, 58 

Rist/158, 449, 472, 640, 700 

Ritter, 242 

Rivers, 95 

Riviere, 54, 128, 274, 296, 300, 336, 639 

Rivolta, 23 

Robin, 93, 241, 605 

Robinson, Beverley, 625, 705 

Robinson, Samuel, 671, 511 

Roger. 340 

Rokitanskv, 101, 103, 260, 431 

Roily, 343" _ 

Romanowski, 487 

Romer, 41, 49, 55, 89, 117, 131, 177 

Rondot, 629 

Ropke, 303, 385 

Roque, 252 

Rosenau, 53 

Rosenberg, Carolyn, 592 

Rosenberger, 245 

Rossalimo, 95 

Rossignol, 117 

Rousseau, 220 

Roux, 23 

Rubel, 565 

Rubinstein, 348 

von Ruck, 261 

Ruedinger, 364 

Ruge, 506 

Rumpf, 246, 643 

Runge, 93 

Russell, John F., 93 



St. Aude, 252 
St. Engel, 189, 196 
Sabourin, 189, 196 
. Sabrazes, 506 
Sahli, 300, 302, 347 
Sajet, 77 
Sale, 459 
Salters, 200 
Sampson, 323 
Sander, 37 
Sauerbruch, 700, 701 
Saugman, 122, 194, 671 
Sawyer, 406 
Saxe, 255 



INDEX OF AUTHORS 



729 



Saxtorph, 665 

Schaffle, 231 

Scheel, 58 

Scheppelmann, 459 

Schern, 245 

Schick, 393 

Schindelka, 104 

Schlatter, 88 

Schmorl, 48, 90, 97 

Schroder, G., 530, 594, 596, 641 

Schroeder, E. C, 20, 43, 51, 53 

Schulze, 98 

Sears, 451 

Selter, 178 

Senator, 248 

Serbonnes, 352 

Sergent, 252, 298, 376, 426 

Sewall, 274, 310, 321, 407, 589 

Shingu, 668 

Shortle, 659 

Simon, 179 

Singer, J. J., 297 

Sluka, 409, 410 

Smith, 98, 198, 246 

Smith, Eustace, 393, 408 

Smith, F. C, 595 

Smith, Theobald, 19, 21, 37, 39, 48, 54 

Sokolowski, 201, 376, 524 

Sommerfeld, 110 

Soparkar, 21 

Sorel, 629 

Sorgo, 39, 201, 202, 220 

Souligoux, 511 

Spaltenholtz, 275, 276 

Spano, 89 

Spehl, 487 

Spengler, 667 

Spindler-Engelsen, 176 

Spivak, 662 

Sprawson, 642 

Squires, 416, 519, 636 

Stadler, 602 

Staehelin, 463 

Staines, 592 

Steffenhagen, 39 

Stern, F., 497 

Stern, R., 112 

Stiller, 99 

Stimson, 348 

Stockwell, 486 

Stokes, 504, 666 

Stoll, 450 

Stoll, H. F., 402, 404, 405, 407, 410 

Stone, 194 

Strandgaard, 207, 231 

Strauss, 21, 46 

Stivelman, 349, 492 

Strieker, 393, 643 

Strickler, 245 

Stuertz, 701 

Sukiennikow, 402 

Suzuki, 245 

Sweet, 70 

Sydenham, 260 



Takaki, 245 

Taute, 26 

Taylor, 112 

Tendeloo, 135, 151, 154 

Tenzer, 343 

Thayer, 433 

Thorn, 123 

Thompson, R., 208 

Thompson, William G., 108 

Thomson, E. Hyslop, 570 

Thomson, St. Clair, 718 

Thormayer, 502 

Thue, 220 

Tibbies, 617 

Tissier, 614 

Tobiesen, 674 

Todd, 223 

Tonelle, 500 

Torrey, 155 

Townsend, 260 

Toyofuko, 120 

Traube, 293 

Tripier, 505 

Trousseau, 101, 506, 654 

Trudeau, 512, 574, 599 

Turner, 700 

Turban, 92, 126, 262 

Turk, 614 

Twitchell, 688, 694 

Uhlenhut, 174 
Ullom, 244 
Ulrici, 604 
Ungermann, 52 
Urban, 115 

Vandervelde, 189 
Vaquez, 506 
Vastenburgh, 51 
Vaughan, 35 
Verneuil, 510 
Villar, 511 
Villemin, 17, 22, 41 
Virchow, 291 
Vischer, 459 
Vitvitzki, 459 
Vogeler, 560, 562, 563 
Voile, 487 
Volk, 117 

Von den Velden, 654 
Voss, 112 

Wagner, 42 
Wainwright, 110 
Walker, 28 
Wallace, 657 
Walsh, 249, 500 
Walsham, 103 
Walshe, 201, 460, 666 
Wang, 414, 540, 658 
Ware, 209 
Warren, B. S., 77 
Warren, E., Ill, 260 
Warstat, 701 



730 



INDEX OF AUTHORS 



Warthin, 90, 91 

Washburn, 20, 603 

Wassermann, 363 

Watson, 522 

Webb, 85, 117, 125, 244, 364, 503, 559, 

565, 592, 674, 686 
Weber 449 

Weber! C, 26, 39, 55, 64 
Weber, F. Parkes, 115, 524 
Weter, Hermann, 123, 524 
Weicher, 126 
Weichselbaum, 46 
Weigert, 135 
Weil, 460 
Weinberg, 88, 539 
Weiss, 424 
Weisz, 522 
Welch, 189 
Weller, 90, 91 
Wells, 631 
Wenkenbach, 466 
West, 101, 105, 210, 274, 458, 460, 461, 

717 
Westermeyer, 89 
Wetherill, 519 
Weygandt, 262 
Wheaton, 232 
White, 82, 249, 476, 635 
Whitla, 50, 51 
Whitney, 449 
Widal, 435, 506 
Wiedersheim, 96 
Wiese, 189 
Wilcox, 81 



Williams, C. Th., 122, 201, 211, 220, 376 

Williams, F. H., 318 

Williams, Mary E., 398, 592 

Williamson, 73 

Wilner, 112 

Wilson, 201, 214 

Wincouroff, 393 

Windle, 104 

Winsch, 220 

Winslow, 576 

Wintrich, 359 

Wolfenden, 721 

Wolff, 207, 220 

Wolff-Eisner, 113, 169, 199, 344, 435 

Wollstein, Martha, 52, 53, 58, 91 

Wolman, 315, 320, 321, 346, 476 

Wood, 50, 100, 279 

Wright, 179, 244 

Wright, B. L., 630 

Wynne, 398 



Xylander, 174 

Yeo, 123 

Zabel, 408 
Zahn, 459 
Zeuner, 108, 109 
Ziegler, 319, 321 
Ziehl-Neelsen, 173 
Ziemann. 67 
Zink, 695 



INDEX OF SUBJECTS, 



A 



Abortion in phthisical women, 551 
Abortive tuberculosis, 385 
diagnosis of, 388 
physical signs of, 387 
symptomatology of, 386 
treatment of, 702 
climatic, 702 
Abscess of chest wall, 510 
ischiorectal, 500 
of lung, 482 
Acid-fast bacilli, 18 

in blood, 245 
in milk, 26 
streptothrix, 27, 486 
in tap water, 27, 346 
Acnitis, 234 

Actinomycosis of lung, 485 
Acute phthisis, 368 

differential diagnosis of, 371 
physical signs of, 371 
pneumonic phthisis, 369 
symptomatology of, 369 
traumatic, miliary, 114 
treatment of, 707 
Addison's disease, 233 
Adenoids, 100 

Adenopathy, bovine bacilli in, 29 
cervical, 401 
tracheobronchial, 402 
diagnosis of, 412 
pathology of, 140, 153 
physical signs of, 402 
prognosis of, 412 
skiagraphy of, 409 
symptoms of, 397 

reflex, 408 
treatment of, 708 
-Adrenalin in hemoptysis, 657 
Adrenals, 233 
Age incidence of tuberculosis, 57, 58, 59, 

61, 66, 416, 389 
Air, stagnant, 576 
"Alarm zone," 336 
Albumin in sputum, 179 
Albuminuria, 247 
Alcohol, 712, 713 
Allergy, 106, 118 
Allyl, 618 
Alopecia, 234 
Altitude and frequency of tuberculosis, 70 



Altitude in phthisiotherapy, 591 
Amenorrhea, 93, 250 
Amphorophony, 312 
Amyloid degeneration, 154 
of intestines, 509 
of kidney, 249, 499 
Anaphylaxis, 33 
Anasarca, 249 
Anatomy, morbid, 134 
Anemia, 143 
Anergy, 106 

Anesthesia in phthisical patients, 518 
Aneurisms of Rasmussen, 149, 203 
Annular shadow, 223 
Anorexia, 224 

in advanced phthisis, 227 

causes of, 225 

diet in, 611 

in incipient phthisis, 333 

treatment of, 661 
Antagonistic diseases, 524 

arteriosclerosis, 524 
cancer, 525 
cardiac, 102, 524 
gout, 524 
nephritis, 524 
scrofula, 125 
syphilis, 525 
Antiformin, 174 
Antipyretics, 651 
Apex appearance in fluoroscope, 317 

percussion of, 285 

predisposition of, 94 
Apical catarrh, 475 

pleurisy, 426 
Appendicitis, 503 

pleurisy and, 426 
Appetite, 424. See Anorexia. 
Arneth's blood picture, 244 
Arrhythmia, 242 
Arsenic, 628 

symptoms of intolerance, 629 
Arteriosclerosis, 524 
Ascites, 502 
Asthma, 102 
Atavistic tendencies, 95 
Atoxyl, 629 

Atropin in hemoptysis, 657 
Auscultation, 296 

in abortive tuberculosis, 387 

in advanced phthisis, 356 

in aged patients, 417 



732 



INDEX OF SUBJECTS 



Auscultation in bronchial adenopathy, 
400 

in incipient phthisis, 336 

over cavities, 361 

in pneumothorax, 464 

single-phase, 297 

sources of error of, 303 

technic of, 296 
Auto-inoculation, 570, 571 
Autonomic nervous system, 252 
Autoserotherapy, 689, 714 
Autosuggestion. See Suggestion. 
Avian bacilli, 22, 25, 28 



B 



Bacilli, tubercle, 17 
acid-fast, 26 
avian, 22, 25, 28 
in blood, 245 
bovine, 24 

in children, 29 
immunity to, 128 
in man, 28 
mutation of, 38 
in phthisis, 29 
prophylaxis of, 540 
in cerebrospinal fluid, 505 
channels of entry of, 40, 47 
cultivation of, 19 
diagnostic value of, 339 
dose necessary for infection, 85 
in dust, 42, 46 
effects of, on tissues, 31 
in embryo, 89 
in fibroid phthisis, 377 
in healed lesions, 35, 132 
in healthy persons, 46, 340 
human, 22, 28 
ingestion of, 40, 49 
inhalation of, 41, 45 
inoculation of, 40 
latency of, 88 
microscopic examination for, 

173 
in milk, 540 
morphology of, 17 
mutation of, 38 
in non-tuberculous patients, 

339, 386 
in ovum, 89 
as parasites, 37 
in placenta, 90 
in pleural exudates, 448 
poisons from, 30 
power of resistance to, 19 
pseudotubercle, 26, 27 



in spermatozoa, 89 
spores in, 18, 19 
in sputum, 18, 173 
staining of, 18, 173 
in tonsils, 100 



Bacilli, ubiquity of, 56 

virulence of, 22 
Bacillus "carriers," 57, 131, 415 
grass, 26 
lepra, 26 
smegma, 26 
Bacteremia, 245 
Bacteria, pyogenic, 35 
Bang system, 92 
Baths, 557 
Bell sound, 166 
Biermer's phenomenon, 360 
Birds, tuberculosis in, 25 
Blood, 243 

cytology of, 243 

effects of high altitude on, 592 

pressure, 242 

prognostic value of, 517 
serum for hemoptysis, 658 
tubercle bacilli in, 245 
Bradycardia, 242 

Breath sounds in advanced phthisis, 356 
amphoric, 361, 465 
bronchial, 302 
bronchovesicular, 303 
cavernous, 361 
in children, 406 
cog-wheel, 300 
feeble, 298 
granular, 300 
metamorphosed, 362 
normal, 298 
rough, 300 
Bronchiectasis, 478, 479 

in tuberculous lungs, 146 
Bronchitis, 478 
Bronchophony, 311 
Bronchopneumonia, tuberculous, 372 
diagnosis of, 374 
etiology of, 372 
in infants, 391 
physical signs of, 373 
prognosis of, 374 
symptoms of, 372 
treatment of, 707 
Broncho-pulmonary spirochetosis, 486 
Bulimia, 225, 226 
Butcher's wart, 40 
Butter as a food, 617 

tubercle bacilli in, 20, 26, 27 



Cachexia, 228 

in infants, 393 
Cacodylates, 629 
Calcification, 138 
Calcium in diarrhea, 665 

in hemoptysis, 658 
Cancer of lung, 483 

pleural effusions in, 444 

tuberculosis and, 525 
Carbohydrates as foods, 618 



INDEX OF SUBJECTS 



733 



Cardiac displacement, 355, 364, 382 

weakness, treatment of, 660 
Cardiovascular symptoms, 239 
"Carriers," 57, 131, 415 
Catarrh, apical, 475 
Cattle, tuberculosis in, 24 
Cavities, 146 

adventitious sounds over, 361 

bacilli in, 35 

basal, 363 

bleeding from, 150, 206 

breath sounds over, 361 

bronchiectatic, 146, 478 

in aged patients, 416 
closed, 149 
cough from, 168 
diagnosis of, 358 
healing of, 150 
mixed infection in, 35 
Much's granules in, 35 
phantom, 363 

prognostic significance of, 519 
rupture of, into pleura, 150 
skiagraphy of, 322 
sputum from, 171 
tympany over, 358 
whispered voice over, 311 
Cerebrospinal fluid, 504 
Cheese as a food, 615 

tubercle bacilli in, 20 
Chest in aged persons, 417 
asymmetry of, 267 
of children, 404 
deformity of, 65 
normal, 266 

radiographic picture of, 314 
Children, pulmonary tuberculosis in, 389 
bovine infection of, 28 
characteristics of, 389 
prognosis of, 394, 412 
symptoms of, 394 
treatment of, 708 
tuberculin test in, 65, 411 
Chloasma phthisicorum, 233 
Chlorosis, 243, 332 
Circumcision infection of wound, 127 
City life, tuberculosis and, 70, 71 ' 
Civilization, tuberculosis and, 57, 69 
Classification of phthisis, 325 
author's, 328 
official, 325 
shortcomings of, 326 
Climate, infection and, 67, 69 
Climates, desert, 559 
mountain, 591 

contra-indications, 594 
indications, 593 
sea, 595 
Climatic treatment, 586 
cost of, 587 

economic aspects of, 586 
vs. open air treatment, 575 
where obtained, 590 
Clothing, 558 



Clubbed fingers, 234 

in fibroid phthisis, 378 
Cod liver oil, 631 

administration, 633 
contra-indications, 632 
indications, 632 
Cog-wheel breathing, 300 
Cold, effects of, on tubercle bacilli, 20 
Colds as predisposing factors, 99 

tubercle bacilli in, 340 
Collapse, during hemorrhages, 205 
induration, 474 
in pneumothorax, 460 
treatment of, 660 
Complement-fixation test, 347 

prognostic value of, 522 
Complexion, 232, 263 
Complications of phthisis, 492 

abscess of chest wall, 510 
appendicitis, 503 
cardiac, 505 
empyema, 444 
gangrene of lung, 499 
influenza, 492 
intestinal tuberculosis, 499 
laryngeal tuberculosis, 493 
meningitis,- 504 
myocarditis, 505 
pericarditis, 505 
peritonitis, 500 ' 

phlebitis, 506 
pleural effusions, 443 
pleurisy, dry, 437 
pneumothorax, 460 
purpura, 510 
pyelitis, 509 
terminal edema, 509 
thrombosis, 506 

influence on prognosis, 367 
tongue, ulceration of, 509 
treatment of, 714 
urogenital tract, 508 
Condiments in diet, 317 
Congenital infection, 90 
Conjugal phthisis, 123 
Constipation, 228 

in meningitis, 504 
in peritonitis, 502 
treatment of, 663 
Corset, 558 
Cough, 164 

in abortive tuberculosis, 386 
in acute phthisis, 370 
in advanced phthisis, 352 
in aged, tuberculous, 416 
in bronchial adenopathy, 400 
diagnostic significance of, 169 
effects of posture on, 168 
emetic, 166 

treatment of, 647 
in fibroid phthisis, 378 
frequency of, 164 
hysterical, 165, 169 
in incipient phthisis, 333 



734 



INDEX OF SUBJECTS 



Cough, paroxysmal, 165 
in infants, 393 

prognostic significance of, 169 

psychotherapy of, 644 

treatment of, 644 
medicinal, 646 
"Cough phenomenon," 317 
Cracked-pot resonance, 361 
Creosote, 622 

administration of, 624 

carbonate, 626 

cinnamate, 626 

contra-indications for, 624 

for cough, 646 

in gastritis, 663 

indications for, 624 

inhalation of, 625 
Crepitation, 305 
Cure, tendencies to, 532 
Cuspidors, 547 
Cyanosis, 233 

in fibroid phthisis, 379 



Death, modes of, 365 

in laryngeal tuberculosis, 498 

in pleurisy, 447 

from pulmonary hemorrhage 

220 
premonitory signs of, 366 
rates from tuberculosis, 69, 79 
Degeneration, amyloid, 154 

stigmata of, 95 
Delirium, 257, 504 
Demineralization, 93 
Dermographism, 252 
Desert climate, 597 
d'Espine's signj 407 
Dextrocardia, 356, 364 
Diabetes, 104 

artificial pneumothorax and, 695 
Diagnosis by animal inoculation, 177 
differential, 471 

from abscess of lung, 482 
from actinomycosis, 485 
from apical catarrh, 475 
from bronchiectasis, 479 
from bronchopulmonary spiro- ! 

chetosis, 486 
from cancer of lung, 483 
from cardiac disease, 487 
from chronic bronchitis, 478 

pulmonary processes, 475 
from gangrene of lung, 482 
from hyperthyroidism, 491 
from influenza, 478 
from mitral stenosis, 488 
from non-specific pulmonary 

infections, 475 
from pleural vomicae, 481 
from pulmonary infarction, 489 
streptotrichosis, 486 



Diagnosis, differential, from rhino- 
pharyngeal disease, 472 
from syphilis of lung, 489 

elementary principles of, 159 

hazards of hasty, 156 

natural method of, 159 

skiagraphy in, 313 
Diaphragm, skiagraphy of, 318 
Diaphragmatic pleurisy, 423 
Diarrhea, 228, 499 

emaciation and, 230 

treatment of, 664 
Diathesis, 86, 92 

arthritic, 524 
Diazo-reaction, 522 
Diet, 608 

carbohydrates in, 618 

condiments in, 618 

eggs in, 615 

fats in, 617 

in hemoptysis, 659 

individualization of, 608 

milk in, 614 

need for special, 610 

proteids in, 613 

salts in, 618 

variety in, 611 

vegetarian, 614 

weight and, 609 
Dietaries, 619 
Dietetic treatment, 608 
Digitalis, in hemoptysis, 657 
Disease vs. infection, 56, 375 
Diseases, antagonistic, 524 
Dispensaries, 603 
Droplet infection, 43, 547 
Duotal, 626 
Dust, 108 

coal, 109 

effects of, on lungs, 109 

in etiology of fibroid phthisis, 376 

inactivity of, 41, 42 

tubercle bacilli in, 20 
Dyspepsia, 223 

in advanced phthisis, 226 

frequency of, 223 
Dysphagia, 495 

in artificial pneumothorax, 687 

treatment of, 721 
Dysphonia, 495 
Dyspnea, 240 

in artificial pneumothorax, 681, 683 

as a danger signal, 567 

in fibroid phthisis, 379, 382 

in infants, 393 

in pneumothorax, 460 

treatment of, 660 

in tuberculosis in the aged, 416 



E 



Ear, 95 

Economic conditions in etiology, 72, 555 



INDEX OF SUBJECTS 



735 



Economic conditions, prognosis and, 523 
Edema, angioneurotic, 233 
cachectic, 508 
of legs, 507 
terminal, 249, 509 
weight of patient and, 230 
Effusion, pleural, 429 

absorption of, 437 
in acute phthisis, 438 
in artificial pneumothorax, 688 
in chronic phthisis, 443 
cytology of fluid in, 435 
displacement of organs in, 434 
Ellis's line in, 431 
exploratory puncture in, 434 
Grocco's sign in, 433 
hemorrhagic, 443 
physical signs of, 430 
in pneumothorax, 467 
prognosis in, 447 
purulent, 444 

symptoms of, 445 
tubercle bacilli in, 448 
Eggs, anorexia and, 224 
dangers of raw, 616 
as a food, 615 
Egotism, 257 

Elastic fibers in sputum, 178 
Ellis's line, 431 
Emaciation, 228 

in acute phthisis, 370 
in advanced phthisis, 353 
in arrested disease, 527 
in artificial pneumothorax, 681 
in children, 397 
effects of, 229 
extent of, 229 
in fibroid phthisis, 378 
in incipient phthisis, 333 
in infants, 393 
in peritonitis, 502 
in phthisis in the aged, 416 
prognostic significance of, 230 
seasonal influences, 231 
Embolism, 507 
gas, 685 
pulmonary, 489 
Embryo, tubercle bacilli in, 88, 90 
Emetin in hemoptysis, 655 
Emphysema in artificial pneumothorax, 
686 
cough in, 165 
cutaneous, 696 
pathology of, 146 
Empyema, 444 

prognosis of, 457 
treatment of, 715 
Endemic diseases in etiology, 105 
Endotoxins, 32 
Environment, change of, 584 
Epidemiology, 56 
Epididymitis, 509 
Ergot in hemoptysis, 657 
Eugenics, tuberculosis and, 551 



Euphoria, 257 
Euthanasia, 257 
Exercise, 569 

effects of, on temperature, 187, 567 
Expectoration, 170. See also Sputum, 

treatment of, 648 
Exposure to infection, 161, 539 
Extrapleural pneumolysis, 700 
Eye, 269 

color of, 263 



Facies, 263 
Fat in diet, 617 

intolerance of, 225 

"phthisis," 196, 231, 378, 527 
treatment of, 707 
Fetus, bacilli in, 89 

infection of, 90 
Fever, 181 

in abortive tuberculosis, 386 

absence of, 195 

in acute phthisis, 353 

in advanced phthisis, 353 

in aged patients, - 416 

anorexia and, 224 

antipyretics in, 651 

in children, 397 

continuous, 192 

cyclic, 192 

diagnostic significance of, 197 

in differential diagnosis, 473 

due to complications, 196 
to medication, 196 

effects of artificial pneumothorax on, 
681 
of rest on, 567, 568 

in fibroid phthisis, 378, 381 

hectic, 193, 353 

hydrotherapy of, 650 

hysterical, 190 

in incipient phthisis, 185, 333 

influence of hemoptysis on, 220 

irregular, 194 

medication for, 651 

mixed infection in, 196 

mountain climate for, 593 

open-air treatment for, 582 

in pleurisy, 430 

premenstrual, 187, 260 

prognostic significance of, 197, 516 

provoked, 186 

pulse in, 240 

rest and, 567 

reversed type, 191 

symptoms of, 185 

in tracheobronchial adenopathy, 397 

treatment of, 648 

in tuberculin reactions, 345 

in tuberculous bronchopneumonia, 
373 
Fibroid phthisis, 375 



736 



INDEX OF SUBJECTS 



Fibroid phthisis in aged, 415 
cough in, 165 
course of, 379 
diagnosis of, 380 
emphysematous, 378 
etiology of, 376 
forms of, 377 
hemoptysis in, 206 
pleural, 382 
prognosis of, 383 
treatment of, 707 
Fibrosis, 138, 151, 380 
Fish in diet, 614, 617 
Fluoroscopy, 316 
Focal reaction, 345 

from creosote, 623 
from iodides, 629 
Foods, carbohydrates, 618 
cheese, 615 
condiments, 618 
eggs, 615 
fish, 614, 617 
milk, 614 

nutritive value of, 609 
protein, 613 
salts, 618 
variety of, 611 
Football games in etiology, 113 
Forced feeding, 609 
Fremitus, vocal, 273 
Friction sounds, 308, 427 

differentiation from rales, 427, 
454 
Friedreich's phenomenon, 359 



Gabbet's stain, 173 

Galloping consumption, 368, 372 

Games, 572 

indoor, 573 

outdoor, 572 
Gangrene of lung, 499 

differentiation from tuberculosis, 
482 
Gastric disturbances, 223 

in advanced phthisis, 226 
treatment of, 663 
Gelatin in hemoptysis, 657 
Genius, tuberculosis and, 258 
Geographical distribution, 69 
Gerhardt's phenomenon, 359 
Germinative transmission, 88 
Giant cells, 135 

in fibrosis, 375 
Glands, bovine bacilli in, 29 

cervical, 491 

enlarged, 265 

hilus, skiagraphy of, 315, 409 

supraclavicular, 252, 428 

tracheobronchial, 140, 153, 396 
Glycerophosphates, 631 
Gout, 524 



Gout and fibroid phthisis, 375, 380 
Graduated labor, 570 
Granules, Much's, 18 

staining of, 176 
Grass bacillus, 26 
Grocco's triangle, 433 
Guaiacol, 626 

antipyretic action of, 651 

carbonate, 626 



Habitus phthisicus, 263 
in children, 404 
Hair, 234 

Handkerchiefs, 549 
Hasty consumption, 368 
Headache, 504 
Head's zones, 254 
Heart, disease of, 102 

differentiation of, from phthisis, 

487 
hemoptvsis and, 212, 488 

displacement of, 355, 364, 382 

palpitation of, 239 

size of, in phthisis, 102 
Heat, action of, on bacilli, 19 
Hectic fever, 193, 353 
Hematemesis, 227 

hemoptysis and, 218 
Hematogenic infection, 48 

in children, 389 
Hemophobia, 215 
Hemoptysis, 201 

in abortive tuberculosis, 386 

in acute phthisis, 370 

respiratory diseases, 211 

adrenalin in, 657 

in advanced phthisis, 353, 366 

in aneurism of the aorta, 213 

in arrested disease, 526 

arthritic, 211 

artificial pneumothorax for, 655, 692 

atropin for, 657 

blood-pressure and, 243 
serum in, 658 

in bronchiectasis, 213, 218, 479 

in bronchitis, 210 

bronchopneumonia after, 221 

calcium for, 658 

camphor for, 658 

causes of, 207, 216 

convalescence from, 659 

death due to, 220, 366 

diagnostic significance of, 209 

digitalis in, 657 

during lactation, 214 
menopause, 713 

epidemics of, 209 

from esophagus, 211, 213 

" false," 210 

fatal, 206, 220 

in fibroid phthisis, 206 



INDEX OF SUBJECTS 



737 



Hemoptysis in heart diseases, 212, 488 

hematemesis and, 218 

hereditary, 216 

hysterical, 215 

in incipient tuberculosis, 334 

influence of, on course of disease, 
220 

in influenza, 212 

menstrual, 214 

morphin in, 654 

of nervous origin, 215 

at onset of phthisis, 204 

overexertion and, 208 

pathology of, 149, 202 

in phthisis in aged, 417 

in pleurisy, 212, 429 

in pregnant women, 214 

premonitory symptoms of, 205 

prognostic significance of, 219, 517 

prophylaxis of, 652 

in pulmonary emphysema, 211 
infarction, 213 

in rhinopharyngeal conditions, 210 

seasonal influences and. 208 

sexual differences and, 207 

spurious, 211 

sputum during, 172 

statistics of, 201 

terminal, 203, 206, 220 

traumatic, 114 

treatment of, 652 
diet in, 659 
medicinal, 656 
tuberculin in, 643 
venesection in, 658 
Hemorrhages, intestinal, 499 
Hemorrhagic phthisis, 207 
Beredity, n7 

biological, 88 

clinical facts of, 92 

definition of, 77 

prognosis and, 515 

social, 88 

statistics of, 87 
Hermann stain, 17 t 
Herpes zoster, 233 
Hilus shadow, 292 

in children, 409 

"dimple," 405 
History of exposure, 161 

in infants, 391 

of patient, 87, 160 

of present illness, 161 

reliability of, 87 
Hoarseness, 170 

in laryngeal tuberculosis, 497 
Hydropneumothorax, 461, 464, 68S 

skiagraphy of, 467 

treatment of, 717 
Hydrotherapy, 557 

for fever, 650 
Hygiene, personal, 556 
Hyperacidity, treatment of, 663 
Hyperesthesia, 253 

47 



Hyperesthesia in pleurisy, 423 
Hypersensitiveness for foreign prot( 
33, 346 

phenomena of, 33 

to tuberculin, 340, 636 
Hyperthyroidism, 334, 491 
Hypotension, arterial, 242 



ICHTHYOL, 627 

Idiocy, 255 

Immigrants, tuberculosis among, 68 

Immunity, 118, 125 

acquired by infection, 119, 125 
clinical facts of, 125 
experimental proof of, 119 
failure of, 128 
"father," 125 
of hospital staffs, 121 
of husbands, 123 
"mother," 124 
of nurses, 121 

phthisis a manifestation of, 127 
of physicians, 121 
through bovine infection, 128 
of wives, 123 
Immunization, with acid-fast bacilli, 26 

with bovine bacilli, 128 
Incipient phthisis. See Phthisis, 
course of, 350 
symptoms of, 332 
treatment of, 702 
Incubation, period of, 392 
Indians, American, tuberculosis among, 

67, 68 
Infancy, tuberculosis in, 371 
diagnosis of, 394 
morbidity during, 538 
prognosis of, 394 
prophylaxis of, 337 
symptoms of, 392 
Infection, tuberculous, 37 
of adults, 43, 543 
age influence on, 74 
of aged persons, 415 
barriers against. 45 
benevolent, 544 
bovine, 53, 541 
bronchogenic, 48 
of children, 117 
congenital, 90 
contact, 40 
disease and, 116, 156 
in children, 396 
droplet, 43, 547 
exposure and, 121, 161, 390 
familial, 391 
of fetus, 90 
frequency of, 57 
hematogenic, 40, 48 
housing conditions and, 42 
of infants, 58, 117 



738 



INDEX OF SUBJECTS 



Infection, tuberculous, by ingestion, 49 

by inhalation, 41 

intrauterine, 90 

lymphogenic, 49 

mixed, 35 

of nurses, 121 

of physicians, 121 

placental, 90 

poverty and, 73 

primary, 391- 

problems of, 37 

in rural populations, 67 

secondary, 36 

sex influences in, 75 

social conditions and, 72 

spermatogenic, 89 

statistics of, 63 

through skin, 40 
sweat, 200 
tonsils, 50, 100 

under normal conditions, 42 
Influenza, 106 

as a complication of phthisis, 492 
in etiology, 106 
Inhalation of bacilli, 41 
Injury as a cause of phthisis, 112 
Insanity, 255 
Insomnia, 258 

due to cough, 165 
treatment of, 661 
Inspection, 263 

in incipient phthisis, 334 
technic of, 267 
Intellect of consumptives, 258 
Internal secretions, 93 
Intestine, tuberculosis of, 154, 228, 499 

diagnosis of, 500 

emaciation and, 230 

pathology of, 154 

symptoms of, 228, 499 
Institutional treatment, 599. See Sana- 

toriums. 
Interlobar pleurisy, 426, 442 
Iodine in treatment of phthisis, 629 
Ischiorectal abscess, 500 
Isolation of tuberculous, 539 



Joints, bovine bacilli in, 29 
tuberculosis of, 74, 389 



Kidneys, 247 

amyloid, 249, 509 

tuberculosis of, diagnosis of, 509 
Kronig's resonant area, 285 

in incipient phthisis, 335 
Kyphoscoliosis, 238 
Kyphosis, 269 



Labor, effects of disease on, 260 
Lagging, 267 

significance of, 268 
Languor, 190, 333 

Larynx in artificial pneumothorax, 695 
tuberculosis of, 493 

diagnosis of, 496 

frequency of, 493 

pathology of, 153 

prognosis in, 498 

smoking and, 559 

symptoms of, 494 

treatment of, 718 
Latent lesions, 57 
Lepra bacilli, 26 
Lesions, tuberculous, among healthy, 57 

frequency of, in children, 57 

initial, 47 

repair of, 150 
Leukocytosis, 243, 244 
! Lime starvation, 92 
I Lips, tuberculous ulceration of, 510 
Liver, tuberculosis of, 155 
Locus minoris resistentise, 92 
Lumbar puncture, 504 
Lungs, tubercles of, 139 

extension of lesion in, 142 

first lesion, 142 

gross appearance, 139 
Lupus vulgaris, 41 

Lycopodium, simulating tubercle bacilli, 
340 



M 



Malaria complicating phthisis, 196 
Malt, 633 
Manometer, 671 

functions of, 573 
Manometric hints, 676 
; Marriage of tuberculous, 125, 550 
| Measles, in etiology, 105 
Meat, 613 

eating, tuberculosis and, 525 

raw, 613 

tubercle bacilli in, 20 
Medication, fever and, 196 

harmless, 622 

hemoptysis and, 208 
Medicinal treatment, 621 

in advanced phthisis, 704 
of children, 711 
Meningitis, 504 

Menopause, tuberculosis during, 713 
Menstruation, disturbances of, 259 

fever during, 188 

hemoptysis during, 214 

vicarious, 214 
Mental traits, 256 
Mercury succinimide, 630 
Metabolism, calcium, 93 

disturbances in, 92 



INDEX OF SUBJECTS 



739 



Metabolism, purin, 525 
Metallic tinkle, 362, 465 
Milk, anorexia and, 224 
in diet, 614 

human, tubercle bacilli in, 540 
tubercle bacilli in, 20, 26, 53 
Miners, rarity of tuberculosis among, 1 10 
Mitral stenosis, hemoptysis in, 212 

tuberculosis and, 103, 488 
Mixed infection, 35 

in cavities, 148 
Morbidity, influence of age on, 58, 389, 

415 
Moro test, 344 
Morphin in hemoptysis, 654 
Mortality, tuberculous, 69, 78 
decline in, 79 

causes of, 82 
effects of campaign against, 80 
sexual differences, 71 
Mountain climates, 591 
Much's granules, 18 

staining of, 176 
Murmur, hemic, in infraclavicular space, 

337 
Murmurs, cardiac, in phthisis, 103 
Muscles, 155 

degeneration of, 269 
pathology of, 155 
spasm of, 269 
wasting of, 229 
Myocarditis, 505 



N 



Nails, 234 

Negroes, tuberculosis in, 68, 83 

Nephritis, 248 

and tuberculosis, 524 
Nervous symptoms, 251 
Neurasthenia, 232, 251 
Nightsweats, 198 

causes of, 198 

in children, 398 

symptoms of, 198 

treatment of, 652 
Nitrites in hemoptysis, 656 
Nocardia, 486 
Nose, tubercle bacilli in, 46 



Obesity, 231, 527, 569, 610 

treatment of, 708 
Occupation, dusty, 108 

in etiology, 76, 107 

for arrested cases, 560, 706 

indoor, 563 
Ochrodermia, 243 
Oliguria, 248 
Onset of phthisis, 161 
acute, 369 



Onset of phthisis, incipient, 331 
with, hemoptj'sis, 204 

Open-air schools, 710 
treatment, 574 

of children, 573 
contra-indications, 585 
for febrile patients, 582 
results obtained from, 584 
technic of, 577 
vs. climatic, 575 
where obtainable, 574 

Ophthalmoreaction, 344 

Opiates for cough, 647 

Opsonic index, 244 

Osteo-arthropathy, pulmonary, 228 

Overcrowding and tuberculosis, 73 

Overfeeding, 609 

precautions necessary while, 612 
symptoms of, 612 

Ovum, tubercle bacilli in, 89 

Ozone, 591 



Pains, 253 

in artificial pneumothorax, 686 

in chest, 253 

treatment of, 661 

in pleurisy, 423 
Palpation, 263, 273 

"light touch," 267 

technic of, 267 
Palpitation, cardiac, 239 
Parrot's law, 140 
Pasteurization of milk, 20 
Pathologist's wart, 40 
Pathology, 134 

of fibroid phthisis, 377 

of phthisis in aged, 415 
Pectoriloquy, 311, 362 
Percussion, 274 

in abortive tuberculosis, 387 

in advanced phthisis, 355 

in aged patients, 417 

aims of, 274 

apical, 285, 290 

auscultation and, 274 

in bronchial adenopathy, 405 

comparative, 281 

diagnostic value of, 295 

hooked finger, 280 

in incipient phthisis, 335 

over cavities, 358 

in pneumothorax, 463 

respiratory, 284 

sources of error in, 289, 290 

technic of, 276 

tidal, 292 
Percutaneous tuber culin test, 341 
Pericarditis, 505 
Perichondritis, 495 
Peritonitis, tuberculous, 500 
Personal hygiene, 556 
Pertussis, 105 



740 



INDEX OF SUBJECTS 



Phagocytes, 135 
Phlebitis, 367, 506 
Phrenicotomie, 601 
Phthisic-genesis, 116 
problems of, 84 
Phthisiophobia, 545 

Phthisiotherapy, psychic factors in, 538 
Phthisis acquired during childhood, 117 
acute, 368 

etiology of, 358, 372 
diagnosis of, 371, 374 
symptoms of, 369, 372 
treatment of, 707 
advanced, 350 

duration of, 364 
oscillating course of, 351 
physical signs of, 354 
symptoms of, 352 
treatment of, 703 
medicinal, 704 
in aged, 415 

course of, 418 
diagnosis of, 418 
etiology of, 415 
frequency of, 415 
physical signs of, 417 
symptoms of, 416 
treatment of, 712 
bovine bacilli in, 29 
clinical forms of, 324 
closed, 122 
complications of, 492 
conflrmata, 325 
conjugal, 123 
curability of, 512 
diabetes and, 104 
a distinctly human disease, 116 
factors predisposing to, 84 
familial, 87 
fat, 231 

fibroid, 375. See Fibroid phthisis, 
hemorrhagic, 207 
incipient, 331 

course of, 350 
curability of, 512 
diagnosis of, 338 

complement-fixation test 

in, 347 
elements of, 338 
sources of error in, 338 
tuberculin test in, 340 
onset of, 331 
physical signs of, 334 
symptoms of, 332 
latency of, 118 
lupus and, 125 

a manifestation of immunity, 127 
marital, 123 
occulta, 325 
"open," 122 
pathology of, 134 
polymorphisms of, 324 
prevention of, 537 
prognosis of, 512 



Phthisis, rarity of, in children, 389, 542 

scrofula and, 125 

stages of, 325 

stigmata of, 263 

traumatic, 112 

treatment of, 702 
Pityriasis tabescentium, 233 

versicolor, 233 
Placenta, tubercle bacilli in, 90 
Placental transmission, 90 
Pleura, accommodative powers of, 462 

anatomy of, 419 

infection of, 422 

pain referred from, 254, 423 

pathology of, 153, 420 

tuberculosis of, 419 
Pleural adhesions, 153, 440, 695 
diagnosis of, 441, 695 
skiagraphy of, 442 

effusion, 429 

in acute phthisis, 438 
in artificial pneumothorax, 688 
in chronic phthisis, 439 
cytology of, 435 
displacement of organs in, 438 
examination of exudate from, 

435 
exploratory puncture for, 434 
hemorrhagic, 443 
interlobar, 443 
physical signs of, 430 
in pneumothorax, 464 
prognosis in, 447 
symptoms of, 429, 445 
tubercle bacilli in, 446 

shock, 684 

vomicae, 481 
Pleurisy, 100, 422 

in acute phthisis, 438 

apical, 426 

beneficial, 453 

course of, 436 

diaphragmatic, 423 

dry, 422, 423 

during chronic phthisis, 453 

effects of, on course of phthisis, 453 

etiology of, 422 

idiopathic, 423 

initial, 429 

interlobar, 443 

non-specific, 452 

pains in, 254, 423 

primary, 422 

prognosis in, 446 

factors influencing, 453 
influence of age in, 554 
in primary, 446 
in purulent, 457 
in secondary, 456 

recurrent, 426 

skiagraphy in, 323, 436, 442 

sudden death in, 448 

symptoms of, 423, 439 

traumatic, 114, 423 



INDEX OF SUBJECTS 



711 



Pleurisy, treatment of, 714 
tuberculous nature of, 448 
varieties of, 422 
Pleximeter, 278 

hooked-finger, 280 
Plumbism, 525 
Pneumokoniosis, 88, 108 
Pneumonia, caseous, 141 

lobar, tuberculosis and, 99, 109 
Pneumopericardium, 466 
Pneumothorax, 458 
artificial, 666 

in advanced phthisis, 692 
apparatus for induction of, 671 
bilateral, 694, 697 
Brauer's method, 668 
cases suitable for, 697 
complications of, 684 
emphysema, 686 
empyema, 689 
gas embolism, 685 
pains, 686 
pleural effusion, 688 

shock, 684 
rupture of lung, 690 
spontaneous pneumo- 
thorax, 686 
contra-indi cations to, 694 
diagnostic, 694 
duration of treatment, 698 
dyspnea in, 683 
fibroid phthisis after, 382 
final pressure allowed, 680 
Forlanini method, 669 
frequency of refills, 680 
gas embolism in, 685 

used for, 674 
for hemoptysis, 656, 692 
indications for, 691 
induction of, 668 
injection in, selection of, point 

for, 674 
in laryngeal tuberculosis, 694 
local anesthesia in, 675 
manometer in, 672, 676 
Murphy's method of, 669, 679 
needle for, 673 
partial, 697 

perforation of lung in, 690 
physical signs of, 683 
pleural adhesions and, 696 

shock and, 684 
pregnancy and, 695 
pupils in, 253 
refilling in, technic of, 679 
results of treatment, 699 
thoracocentesis in, 675 
diagnostic, 694 
hemoptysis and, 216 
in phthisis, 460 

diagnosis of, 465 
displacement of organs in, 462 
double, 463 
effusion in, 464 



Pneumothorax in phthisis, frequencv of 
460 

latent, 463 

localized, 462, 468 

mute, 463 

partial, 462, 468 

pathology of, 150, 458 

physical signs of, 463 

prognosis in, 469 

skiagraphy in, 467 

succussion sound in, 464 

symptoms of, 460 

tapping of, 462 
"providential," 717 
spontaneous, 458 
treatment of, 715 
Poisons of tubercle bacilli, 30 
Polyuria, 248 
Polyserositis, 447 
Poverty, prognosis of phthisis and, 523 

tuberculosis and, 72, 73 
Predisposition, 84 

anatomical factors and, 94 
constitutional factors and, 94 
diabetes and, 104 

diseases of heart and bloodvessels 
and, 102 

of respiratory tract and, 99 
hereditary, 87 
influenza and, 105 
injury and, 112 
metabolic, 92 
nature of, 129 
physical stigmata of, 94 
theories of, 86 
Pregnancy, 260, 551 

artificial pneumothorax and, 695 
infection during, 91 
tuberculosis and, 519 
Procreation by phthisical patients, 551 
Prognosis, 512 

in abortive tuberculosis, 385, 513 
activity of disease and, 516 
in acute phthisis, 374, 513 
Arneth's blood picture in, 244 
in arrested disease, 526 
cavities and, 519 
in children, 412 

complement-fixation test in, 522 
complicating influenza and, 518 
complications and, 517 
diazo reaction in, 522 
economic conditions and, 523 
elements of, 513 
emaciation and, 527 
fever and, 197, 516 
in fibroid phthisis, 381 
hemoptysis and, 219, 515, 517 
heredity and, 514 
history of patient and, 514 
in infants, 394 

of laryngeal tuberculosis, 498 
physical signs in, 517 
pleurisy and, 446, 447, 456, 518 



742 



INDEX OF SUBJECTS 



Prognosis of pneumothorax, 469 

pregnancy and, 519 

pulse-rate in, 517 

in quiescent disease, 526 

special tests in, 522 

surgical operations and, 518 

symptomatology and, 516 

thrombosis and, 508 

urochromogen reaction in, 522 

in various forms of phthisis, 513 
Prolificity of tuberculous, 260 
Prophylaxis, 537 

in adults, 543 

in children, 541 

duties of community in, 549 

failure of, 83 

in infants, 537 

marriage and, 550 

of phthisis, 544 

of reinfection, 542 
Proteid foods, 613 
Psychasthenia, 251 
Psychic traits, 255 
Psychotherapy, 535 • 

with medication, 621 

with tuberculin, 641 
Pulse, 240 

in abortive tuberculosis, 387 

in aged tuberculous, 416 

in incipient tuberculosis, 334 

instability of, 334 

in meningitis, 504 

in pleural effusions, 430 

prognostic value of, 517 

slow, 242 
Pupils, dilatation of, 252, 428 

inequality of, 248 

in pleurisy, 428 
Pus, tuberculous, 138 
Pyopneumothorax, treatment of, 718 



Racial susceptibility to tuberculosis, 67 
Radiography, 316. See Skiagraphy. 
Rales in advanced lesions, 357 

after hemoptysis, 357 

atelectatic, 309 

in bronchiectasis, 480 

cavernous, 362 

crepitant, 305 

differentiation from frictions, 427, 
434 
from muscle sounds, 309 

in incipient phthisis, 337 

marginal, 310 

moist, 306 

provoked, 308 

sibilant, 307 

sonorous, 307 

spurious, 309 
Reaction, tuberculin, 347 



Reaction, tuberculin, clinical value of, 346 
conjunctival, 344 
cutaneous, 341 
dangers of, 347 
diagnostic value of, 342, 346 
focal, 345 
local, 345 

specificity of, 34, 343, 346 
Reinfection, autogenic, 130 
endogenic, 130 
exogenic, 130 
in hospital inmates, 121 
in human beings, 120 
influence of dose, 120 
metastatic, 130 
prophylaxis of, 542 
Relapses, 362 

dangers of, 706 
Remineralization, 631 
Renal symptoms, 247 
Reptilian tubercle bacilli, 25 
Rest-cure, 565 

contra-indications for, 568 
for fever, 648 
indications for, 566 
principles of, 565 
Ribs, ossification of, 95 



S 



Salt in diet, 618 

in hemoptysis, 655 
Sanatorium treatment, 599 

for incipient phthisis, 702 
indications for, 606 
Sanatoriums, 599 

causes of failure of, 605 

cures in, 532 

discipline in, 555 

educational value of, 603 

gains in weight in, 230 

limitations of, 600 

non-tuberculous cases in, 157, 385 

prophylactic value of, 603 

scope of, 599 
Scarlet fever, 105 
Sclerosis, 138, 375 
Scrofula, 125, 524 
Sea climates, 395 

voyages, 396 
Selfishness, 256 
Semen, tubercle bacilli in, 89 
Senile phthisis, 415 
Servants, domestic, 538 
Sex, in hemoptysis, 208 

influence on mortality, 75 

in prognosis, 515 
Sexual disturbances, 259 

excesses, 261 

irritability, 261 
Shoulder, pain in, 253, 324 
Skiagraphy, 313 

in advanced phthisis, 322 



INDEX OF SUBJECTS 



743 



Skiagraphy, annular shadow in, 223 

apices in, 317 

in bronchial adenopathy, 409 

cavities in, 323 

in incipient phthisis, 317 

in pleurisy, 436 

in pneumothorax, 467 

sources of error in, 321 
Skin, 233 

infection through, 40 

eruptions on, 233 

lesions, rarity of, 126 

stigmata on, 264 
Sleeping porches, 579 
Smegma bacillus, 26 
Smith's sign, 408 
Smoking, 558, 645 
Softening of lesion, 138 
Somnolence, 259 
Specific treatment, 634 

of children, 711 
Spermatogenic infection, 89 
Spermatozoa, tubercle bacilli in, 89 
Spleen, tuberculosis of, 155 
Sputum in abortive tuberculosis, 387 

in advanced phthisis, 352 

albumin in, 179 

animal inoculation of, 177 

bacilli in, 20 

collection of specimens of, 172 

cytology of, 179 

dangers of swallowing, 645 

disposal of, 547 

elastic tissue in, 178 

examination of, 173, 174, 179 

fetid, 383 

in gangrene of lung, 482, 499 

infectivity of, 547 

inoculation of, 177 

flasks, 547 

macroscopic appearance of, 170 

number of bacilli in, 177 

nummular, 171 

odor, 171 

streaky, 208, 210, 472 
Status bacillaris, 91 
Stethoscope, 297 
Stigmata of phthisis, 263 
Stomach, dilatation of, 226 

tuberculous ulceration of, 226 
Stomatitis, aphthous, 367 
Street-sweepers, rarity of tuberculosis 

among, 110 
Streptothrix, acid fast, 27, 486 
Streptotrichosis of lung, 486 
Succinimide of mercury, 630 
Succussion sound, 464 
Suggestion, amenability to, 255 

climatic treatment and, 588 

in treatment, 534 

in tuberculin treatment, 534, 641 
Superalimentation, 609 

dangers of, 612 

hemoptysis and, 208 



Superalimentation, necessary precautions 

in, 612 
Superinfection, 119 
Surgical operations, 700 
Sweats, 198 

infectiousness of, 234 
Symptomatic treatment, 644 
Symptomatology, importance of, 162 
Syphilis of lung, 490 

prognosis and, 525 



Tachycardia, 240 

in abortive tuberculosis, 387 

high altitude and, 594 

in incipient phthisis, 334 

paroxysmal, 240, 334, 465 

permanent, 240 

prognosis and, 517 

treatment of, 660 
Temperature, effects of work on, 571 

exercise and, 187 

instability of, 187 

normal, 184 

subnormal, 195 

taking of, 182 

types of, in phthisis, 191 
Tents, 578, 579 
Thermometers, 181 
Thorax, asymmetry of, 269 

deformity of, 96 

normal, 269 

phthisical, 265 
Thrombosis, 506 

of femoral vein, 507 

of jugular vein, 508 
Thyroid, enlargement of, 265, 334, 491 
Timothy-grass bacillus, 26, 28 
Tobacco, use of, 558 
Tongue, tuberculous ulcers on, 510 
Tonsils as channels of entry, 100 

infection through, 50 

tubercle bacilli in, 100 
Toxemia, psychic effects of, 255 
Toxins, tuberculous, 31 

hypersensitiveness to, 342 
Trachea, displacement of, 364 
Tracheal tone, Williams', 359 
Tracheobronchial adenopathy, 396 
cough in, 400 
diagnosis of, 402, 411 
emaciation in, 397 
fever in, 397 
prognosis in, 412 
skiagraphy in, 409 
tuberculin diagnosis in, 411 
Tracheophony, 407 
Transmission, germinal, 88 

placental, 89, 90 

uterine, 89 
Traumatic tuberculosis, 112 
acute, 114 



X, 



3/9 ir^ 7 



'4^3l 



744 



INDEX OF SUBJECTS 



3 3 



Traumatic tuberulosis, clinical manifes- 
tations of, 114 
by cont recoup, 113 
surgical injuries and, 115 
Treatment of acute phthisis, 707 
of advanced phthisis, 706 
of arrested cases, 706 
climatic, 586 
of complications, 714 
of convalescents, 706 
dietetic, 608 

economic aspects of, 555 
of fibroid phthisis, 707 
of incipient phthisis, 702 
indications for, 529 . 
individualization in, 605 
institutional, 599 
medicinal, 621 
open-air, 574 

of children, 709 
operative, 666 
pneumothorax, 666 
psychic influences in, 533 
psychotherapy, 535 
suggestion in, 534 
symptomatic, 644 
tuber culin, 634 
Tubercle bacilli, 17 ^ 

in abortive tuberculosis, 388 
effects of cold on, 20 

of desiccation on, 20 
of heat on, 20 
of light on, 20 
in fetus, 89 
ingestion of, 49 
inhalation of, 41 
in ovary, 90 
in placenta, 90, 92 
in semen, 89 
in sputum, 172 

animal inoculation of, 177 
diagnostic value of, 339 
examination for, 174 
types of, 23 
ubiquity of, 56 
in urine, 509 
Tubercles, calcification of, 138 
caseation of, 137 
histology of, 134 
structure of, 134 
Tuberculides, 393 
Tuberculin, 31 

action of, 32, 636 
antibodies in, 32 
chemistrjr of, 32 
clinical effects of, 638 

value of, 342, 346, 394 
diagnostic value of, 346 
dosage of, 639 
hypersensitiveness to, 345 
preparation of, method of, 31 
reaction of, 342, 344, 345 
specificity of, 34, 343 
tests, 65, 340 



Tuberculin tests in children, 68, 411 
treatment, 634 

administration of, 639 
in children, 711 
dangers from, 642 
dilutions in, 639 
dosage, 639 

evidence of inefficiency, 639 
hemoptysis during, 643 
inefficacy in animals, 637 
lack of statistics of, 639 
pyschic effects of, 534, 641 
tolerance of, 636 

Tuberculolysins, 33 

Tuberculosis vs. phthisis, 116 

Typhoid fever in etiology, 107 



Ulcer, tuberculous, of intestine, 154, 499 
of mucous membranes, 509 
of stomach, 226 

Urbanization and tuberculosis, 71, 83 

Uremia, 250 

Urine, tubercle bacilli in, 247 

Urochromogen reaction, 522 

Urogenital tract, tuberculosis in, 508 



Vas deferens, tuberculosis of, 509 
Veins, enlarged, on chest, 265 

in children, 404 
Venesection in hemoptysis, 658 

in pneumothorax, 717 
Ventilation, 576 
Voice sounds, 310 
Vomiting, 167 

after cough, 166 
; Virgin soil, 127 



W 



Wages, tuberculosis and, 73, 77, 111 
War, tuberculosis and, 77, 157 
Weight, loss in, 228 

in children, 397 

seasonal variation in, 231 
Whispered voice, 310 
Williams' tracheal tone, 359 
Wintrich's phenomenon, 359 



X 



X-rays. See Skiagraphy, 313 



Zomotherapy, 613 






i 



CONGRESS 



